**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to provide an environment that was free of accident hazards for one (Resident #1) of five residents reviewed for accidents. -The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents when Resident #1 cut his wrist with a sharp object, had to be hospitalized with a 4cm laceration to his wrist and was admitted for a psychiatric evaluation. Resident #1 had diagnoses of mental illness and IDD, a history of having razors in his possession, and a history of aggressive behaviors. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 8/12/25 and ended on 8/14/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk for accidents that could lead to serious injury, harm, or death. Findings included: Record review of Resident #1's face sheet, dated 8/15/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 8/12/25. Resident #1 had diagnoses that included: vascular dementia (brain disorder that affects thinking, memory, and behavior caused by a stroke), type 2 diabetes (body's inability to control blood sugar), schizophrenia (mental disorder that affects thinking, mood, and behavior), and moderate IDD (significant limitations in intellectual and adaptive behaviors). Record review of Resident 1's quarterly MDS assessment, dated 6/18/25, reflected the resident's BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section D-Mood, reflected Resident #1 had not shown any mood problems within the last two weeks and rarely isolated. The MDS Assessment under Section E-Behavior, reflected Resident #1 had not exhibited any behaviors. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required supervision with all ADL's. Record review of Resident #1's care plan, revised 8/12/25, reflected the resident had a potential for mood problem r/t dx of schizophrenia with interventions that included: administering medications as ordered, providing a program of activities, behavioral health consult as needed, monitoring and recording change in mood or possession of weapons and reporting to MD as needed. Further review of the document reflected Resident #1 had a behavior problem AEB physical aggression with interventions that included: anticipating the resident's needs, providing positive interaction and attention, administering medication as ordered, assessing contributing sensory deficits, providing physical and verbal cues to alleviate anxiety, intervening as necessary to protect the rights and safety of others and self, modifying environment, and monitoring, documenting and reporting PRN any s/sx of resident posing danger to self and others. Record review of Resident #1's psychiatric progress note, dated 7/28/25, reflected in part the following: Reason for Referral:[Resident #1] was referred to [Behavioral Health Provider] due to: vascular dementia, schizophrenia, agitation, aggressive behavior.Chief Complaint/HPI:[Resident #1] is being seen today for the management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. [Resident #1's] psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the [Resident #1's] condition and to prevent relapse or hospitalization. [Resident #1] reports to I'm okay. Staff report [Resident #1's] behavior has improved.[Resident #1] is seen in the secure memory care unit. [Resident #1] does not appear to be feeling sad, nervous, angry, or elated today. [Resident #1] presents no delusions and does not appear to be responding to internal stimuli. [Resident #1] has been sleeping well, with adequate daytime energy. [Resident #1] has a good appetite. [Resident #1] participates in some of the available activities.Current Medication:Other MD:1 Benztropine Mes 0.5 Mg Tab SIG: Take 1 twice daily (used to treat Parkinson's Disease)2 Melatonin 3 Mg Odt SIG: 1 po q 24h (a natural hormone that regulates sleep)3 Oxcarbazepine 150 Mg Tablet SIG: Take 1 twice daily (used to treat seizure and mood disorder)4 Risperdal 1 Mg Tablet SIG: 1 at night (anti-psychotic medication)5 Sertraline Hcl 100 Mg Tablet SIG: 2 po qd (used to treat mood disorder)6 Trazodone 50 Mg Tablet SIG: 1 po qhs (used to regulate sleep and stabilize mood) Assessment/Plan:Schizophrenia: Sertraline, RisperidoneSleep: Trazodone, MelatoninSz and mood stabilization: Oxcarbazepine. Record review of Resident #1's progress notes, dated 7/1/25 at 7:08 AM by LVN Q, reflected the following: CNA removed razors from [Resident #1's] room and [Resident #1] became upset, knocking carts over in hallway and attempting to grab and hit CNA. CNA went into nursing station and [Resident #1] sttempted [sic] to reach over door to hit and grab CNA. [Resident #1] made threats that he was going to come after CNA and ‘get him.' [LVN Q] explained that razors are not allowed to be left in the room and that staff has to follow the regulations. [Resident #1] yelled at [LVN Q] that he can have them and that he had a lot of razors in his room. Record review of Resident #1's progress notes, dated 8/12/25 at 1:28 PM by LVN A, reflected the following: [Resident #1] was informed that the money is available but [Resident #1] continued to want the money immediately, the business lady informed resident that she will bring [Resident #1] his money as soon as she cashes [Resident #1's] check but [Resident #1] did not want to wait., [Resident #1] continued to kick the door and asking for his money. Record review of Resident #1's progress notes, dated 8/12/25 at 1:33 PM by LVN A, reflected the following:[LVN A] was called to come to the entrance door of the unit by [Activity Director], on arrival [LVN A] noticed [Resident #1] bleeding from his wrist and that [Resident #1] had cut his wrist with a razor and was bleeding heavily. [LVN A] collected towel and applied pressure to stop the bleeding. [LVN A] asked for other employees to come help stop the bleeding by applying pressure. [LVN A] called 911 and asked for paramedics and police to come and transport [Resident #1] to [local hospital] for eval and treatment. Record review of Resident #1's progress notes, dated 8/12/25 at 1:43 PM by LVN A, reflected the following: [NP] notified of [Resident #1] cutting his wrist and [Resident #1] was being sent to [local hospital] for treatment and eval. Paramedics arrived and transported [Resident #1] to ER. Record review of Resident #1's hospital records, dated 8/12/25, reflected in part the following: HPI: [Resident #1] is a 70 y.o male who presents with 4cm left wrist laceration after [Resident #1] became angry at his group home for not giving him the cash from his social security checks fast enough. [Resident #1] States he was not trying to kill himself, he was just trying to make a point. [Resident #1] denies any decreased sensation distal (farther from) to the laceration. [Resident #1] with difficulty of wrist flexion (action of bending). [Resident #1] has no issue with MCP (knuckle), PIP (middle joint of each finger), or DIP (fingertips) flexion.Physical Exam:Laceration: Volar laceration (involves multiple structures) of the proximal forearm. Exposed tendon within the laceration most likely FCR (tendons that help bend wrist). Tendon appears partially intact. FDS and FDP (tendons that help bend fingers) intact. [Resident #1] with severe difficulty in wrist flexion. FPL (tendons that help bend thumb) intact. [Resident #1] denies decreased sensation distal to the laceration. Strong ulnar artery (major blood vessel in forearm) pulse using Doppler. Weak radial pulse (pulse in wrist) using Doppler.Flexlon Cascade (natural resting posture of hand): No scissoringTendons: FDS and FDP intact in the index, middle, ring, small finger. FPL intact in thumb. No extensor lag (inability to extend) present. Able to fully extend all digits.Sensation: Sensation intact to light touch on the radial and ulnar border aspect of all digits. Sensation intact to light touch in the radial, ulnar and median nerve (major nerve that runs from arm to hand) distribution.Vascular: Less than 2 sec capillary refill present in all digits.Motor: Positive [NAME], PIN (nerves responsible for motor function), ulnar nerve function.Imaging: XR left hand: There is a soft tissue laceration but no acute fracture.Assessment:-Left wrist laceration-Suicidal ideation-Admit [Resident #1] to intermediate care-Bedside sitter-Psychiatric consultation-Bedside repair (closed laceration). Record review of Resident #1's EHR reflected the resident was discharged from the facility and at a local hospital; therefore, Resident #1 was unable to be interviewed. In an interview on 8/15/25 at 9:25 AM with the Administrator and DON, the Administrator stated Residen#1 resided on the secured unit due to diagnosis of dementia and was receiving psychiatric services for management of medication and behaviors. She stated on 8/12/25 it was reported that Resident #1 became frustrated about not receiving his money and pulled out a sharp object and cut his wrist. The Administrator stated the Activity Director was on the unit and attempted to stop Resident #1 however, it happened so fast he was unable to. The DON stated she was called onto the unit and assisted with stopping the bleeding until EMS arrived. She stated she was occupied with tending to the wound and never saw the sharp object that Resident #1 used. The Administrator also denied seeing the sharp object and stated she did not know how Resident #1 could have obtained a sharp object to cut himself as all sharp objects were locked up. The DON stated it had not been reported that Resident #1 expressed any thoughts of suicide or behaviors just prior to the incident; however, he was diagnosed with schizophrenia and had a history of aggression when things did not happen right when he wanted them to. The Administrator stated staff did a full sweep of the entire facility immediately after the incident to check for and remove any unsafe objects. The DON stated Resident #1 had a parole officer; however, the facility did not have any information about why he was on parole and the resident's parole officer had not visited the facility. The DON stated Resident #1 was his own responsible party and did not have any family involvement. In an interview on 8/15/25 at 9:42 AM, the Activity Director stated he was on the unit preparing to take residents out for a smoke break when he heard Resident #1 upset and kicking on the door. The Activity Director stated he went to talk to Resident #1 to calm him down and the resident stated he was upset because he did not have his money. The Activity Director stated Resident #1 said he was going to cut his wrist, then pulled out a sharp object and proceeded to do cut himself. The Activity Director stated he tried to stop Resident #1 but was unable to. The AD stated he did not know what object Resident #1 used to cut himself and he never saw the object afterwards. He stated he walked away and let the nurse take over. He stated he immediately called for LVN A and CNA B to help, and they came to take over. The Activity Director stated he interacted with Resident #1 all the time because the resident was a smoker, and he often supervised the smoke breaks. The Activity Director stated Resident #1 was normally calm especially if he could smoke, and he had never seen him agitated or aggressive. The Activity Director stated he always made sure the residents who smoked had cigarettes and went to break on time because that made them happy. He denied having concerns for any residents being abused or neglected at the facility. The Activity Director stated staff were often trained on abuse and neglect and had in-services regarding resident safety, rights, and suicidal behaviors after the incident this week. In an interview on 8/15/25 at 10:17 AM, the BOM stated Resident #1's funds were in the facility's trust fund, and he would get $45 a month. The BOM stated initially there were some issues with the facility becoming payee over Resident #1's money, but she was finally able to get it worked out and the resident had 2 checks for $45 available. The BOM stated she was just waiting for the Administrator to go to the bank and cash the checks. The BOM stated Resident #1 became a little agitated after she explained that the checks were available but needed to be cashed. In an interview on 8/15/25 at 10:44 AM, LVN A stated he worked at the facility for 10 years and worked with Resident #1 on the male secured unit. LVN A stated he worked on 8/12/25 when the incident occurred. LVN A stated he was assisting other residents in the dining area on the unit when the Activity Director called for his assistance because Resident #1 was agitated. LVN A stated by the time he made it down the hallway, Resident #1 had cut himself and he saw a lot of blood. LVN A stated he grabbed towels and wrapped them on Resident #1's arm to stop the bleeding while calling 911. LVN A stated he did not see the object that Resident #1 used and could not state what happened to it after the incident. LVN A stated Resident #1 had a history of being aggressive towards other residents but was normally calm until something triggered him. LVN A stated Resident #1 had been involved in physical altercations with other residents for them getting in his space. He stated Resident #1 never showed any signs of being suicidal. LVN A stated Resident #1 was independent with most ADL's; however, the CNAs were still expected to monitor him while shaving and to immediately dispose of the razors in a sharps container. LVN A stated the residents were not allowed to keep disposable razors in their rooms, and he denied ever seeing any razors left in resident rooms. He stated new razors were always locked in a supply closet that was on the unit. In an interview on 8/15/25 at 10:58 AM, Resident #4 stated he felt safe at the facility. He stated staff assisted him with ADL's as needed; however, he was able to do some things on his own and it made him feel good about himself. Resident #4 stated he used to keep a disposable razor in his room because he liked to shave himself daily without bothering staff, but all razors were removed a couple of days ago after an incident happened at the facility. Resident #4 stated he understood it was for safety, but it also felt like they were taking some of his independence. Resident #4 stated staff told him that he could still shave himself every day, they just had to bring in the razor and monitor him. In an interview on 8/15/25 at 11:08 AM, the Floor Technician stated he cleaned the floors at the facility, including in resident rooms. He stated when cleaning in the resident rooms, there were times he saw disposable razors in the bathrooms prior to the incident. The Floor Technician stated he did not remove the razors because he had not been told to do so and he did not report it to nursing because he thought the residents were allowed to have the disposable razors to shave. In an interview on 8/15/25 at 11:15 AM, CNA B stated she worked at the facility since 1988. She stated she worked on the male secured unit with Resident #1 and worked on 8/12/25 when the incident occurred. CNA B stated Resident #1 had been asking about his money all morning but did not seem agitated at first. CNA B stated the BOM came to the unit to speak to Resident #1 about his money around lunch time and shortly after, the resident started kicking the door and repeating that he wanted his money. CNA B stated she began directing all other residents to the dining area for safety and the Activity Director was with Resident #1 trying to calm him down. CNA B stated she suddenly heard more yelling and when she turned around, she saw blood coming from Resident #1. She stated LVN A went to help Resident #1 while she remained with the other residents. She stated she was not sure how Resident #1 was able to get anything sharp to cut himself with. CNA B stated they kept razors for shaving locked in the closet. CNA B stated when she showered residents, she would assist them with shaving if needed then immediately put the razors in a sharps container. She denied ever leaving a razor out and in a resident's possession, not even the residents who were able to shave themselves. The CNA stated she could not speak for all staff and there were times they would come on shift and find razors left out prior to the incident. CNA B stated she would always remove any razors she found. In an interview on 8/15/25 at 12:01 PM, CNA C stated she worked on the male secured unit and was familiar with Resident #1; however, she did not work on 8/12/25 when the incident occurred. CNA C described Resident #1 as pleasant and denied ever seeing him agitated or exhibiting signs of being suicidal. CNA C stated the aides were responsible for assisting and monitoring residents with shaving and had to remove the razors immediately. She stated she would always place the razors in a sharps container outside of the resident rooms. CNA C stated staff were expected to check drawers, sinks, and bathrooms in resident rooms daily for things like silverware, razors, electric shavers, or other items that could be unsafe before and after the incident. CNA C stated sometimes during her checks she would find disposable razors left in the bathrooms and she would remove them and report it to the nurse. She denied seeing any razors since the incident occurred. CNA C stated the disposable razors were locked in the supply closet; however, the residents were smart and would sometimes figure out the code by watching staff. CNA C stated she found Resident #1 inside of the supply closet one day and after she reported it the code was changed. CNA C stated although she was off on 8/12/25, the DON called and in-serviced her by phone regarding resident safety, rights, behaviors and abuse and neglect. She stated prior to the incident, staff received those trainings periodically. Further interview on 8/15/25 at 5:31 PM, the Administrator stated the expectation was for staff to check resident rooms with a fine-tooth comb for unsafe items and monitor residents closely for any changes in mood or behavior. She stated management would also complete ambassador rounds to check rooms and visit with residents. The Administrator stated reports would be shared every morning during stand-up to discuss any incidents or changes in residents. The Administrator stated they would continue to educate residents and RPs on what items are allowed in rooms. She stated staff would also continue to be educated on maintaining a safe environment, which would include being aware of packages received at the facility. The Administrator stated staff were aware of resident rights and that permission was needed to check personal belongings; however, safety was first. The Administrator stated not adequately supervising residents and ensuring a safe environment could place the residents at risk of harm. Review of the facility's policy titled Safety of Residents, revised August 2020, revealed in part the following:Purpose: To provide a safe environment for residents and Facility Staff. Policy: Residents who display combative behaviors receive prompt and appropriate intervention. Procedure:I. ScreeningA. Prior to admission, all inquiries are evaluated by the Director of Nursing (DON) for potential combative behavior based on historical data, diagnoses, and medication regimen. II. PreventionA. Upon admission, residents will be monitored for behavioral triggers including, but not limited to:i. Tension in body language or facial expression;ii. Increased pacing or wandering;iii. Elevated voice volume;iv. Rapid mood changes; andv. Increased anger or frustration. III. Response to Unsafe BehaviorA. If a resident's behavior becomes abusive, hostile, or unmanageable in a way that compromises his or her safety or the safety of others, the Charge Nurse and the DON are notified immediately.B. B. The Charge Nurse will:i. Identify and remove the source of the problem, if known;ii. Calmly reassure the resident and direct him/her to a more relaxing area; andiii. Maintain one-on-one supervision of the resident until the behavior has subsided or other arrangements have been secured. C. The DON will:i. Notify the resident's Attending Physician and obtain orders, if necessary;ii. Notify the resident's representative;iii. Notify the Administrator; andiv. Task an available CNA to ensure all other residents are safe and provide calm reassurance on the unit. Record review of a document provided by the Administrator, untitled and undated, revealed in part the following: .Safety ConcernsThe following is a list of items that are not allowed in resident rooms due to potential for harm/fire/or other dangerous situations:. Sharp objects, scissors, knives, razors, unsecured glass objects, crochet needles. The non-compliance was identified as past non-compliance (PNC). The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review on 8/15/25 of a document provided by the Administrator titled AD HOC Quality Assurance and Performance Improvement Plan, dated 8/13/25, reflected a QAPI meeting was held to discuss the incident and interventions put in place, which included: Resident #1 being sent to an acute care hospital for evaluation and/or treatment, daily ambassador rounding to check for unsafe items in resident rooms, the facility providing extra cigarettes as needed to prevent related agitation/behaviors, inventory sheets completed at admission and updated for all current residents, staff educated on unsafe items not allowed in resident rooms, behavior identification and suicidal thoughts and de-escalation, notification and documentation of incidents, off-cycle resident council meeting to review items not allowed in rooms and inventory sheets with residents. Record review on 8/15/25 of Resident #1's EHR reflected the resident was discharged from the facility to the local hospital on 8/12/25. Record review on 8/15/25 of documents provided by the DON titled Inventory of Personal Belongings,, dated 8/12/25, reflected all current residents' personal inventory was updated. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding checking for unsafe items in resident rooms during rounds, updating resident inventory sheets, and policy and procedures for abuse and neglect and resident rights. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding identifying behaviors and suicidal prevention. Record review on 8/15/25 of a check-off resident census provided by the Administrator, dated 8/12/25-8/15/25, reflected safety checks of all resident rooms began and was on-going to ensure a safe environment. Observations on 8/15/25 from 9:45 AM-11:00 AM, of the facility's environment including resident rooms and bathrooms, shower rooms, and supply closets reflected the environment was free of potential hazardous and unsafe items. All razors were locked in the supply closet and requires a code to enter. Record review on 8/15/25 of Residents #1, #2, #3, #4, and #5 EHRs, who were all at risk for accidents, revealed their care plans included interventions to address ADL and behavioral needs as appropriate to ensure adequate supervision/assistance and safety. Resident #1's care plan was revised on 8/12/25 to reflect his behavior and harm to self with appropriate interventions. Interviews on 8/15/25 from 10:15 AM-11:00 AM with Resident #4's RP and Residents #1, #2, #3, #4, and #5, who were all at risk of accidents, revealed no concerns for inadequate supervision or safety. Interview on 8/15/25 at 4:43 PM with the MD revealed she was made aware of Resident #1's incident on 8/12/25. The MD stated she was also a part of the QAPI meeting on 8/13/25 and agreed with interventions put in place to ensure the safety of all residents. The MD stated the IDT would have to review the final evaluation from the hospital to determine if Resident #1 would be a good fit for the facility and appropriate protocol would be followed. Interviews on 8/15/25 from 9:25 AM-5:31 PM conducted with the Administrator, DON, nurses and CNAs: LVN A (1st shift/weekdays), CNA B (1st shift/rotating days), CNA C (1st shift/rotating days), RN D (1st shift/rotating days), CNA E (1st shift/rotating days), RN F (1st shift/weekdays), CNA G (1st shift/rotating days), CNA H (2nd shift/ rotating days), CNA I (2nd shift/ rotating days), RN J (2nd shift//weekdays), RN K (1st/2nd shift/double weekends), CNA L (2nd shift/rotating days), RN M (PRN), LVN N (3rd shift/weekdays), CNA O (3rd shift/ rotating days), CNA P (3rd shift/ rotating days), indicated they all participated in in-services 8/12/25-8/14/25, and prior to the start their shifts. All staff were able to state that they were responsible for ensuring the safety of all residents by checking all resident rooms and common areas for unsafe items, removing the items and reporting it to the Administrator. All staff were able to state how to identify s/sx of suicidal ideations and changes in residents' mental and physical conditions, who to report it to, and to documents all incidents. The Administrator stated it was management's responsibility to ensure that staff were educated on identifying and reporting changes in residents' mental and physical conditions, behaviors, and ensuring the safety of residents, and ongoing trainings to ensure retention of education. The Administrator stated management would be updated on any changes or updates daily during stand-up meetings. The DON stated resident behaviors were monitored, the medical director involved, and psychiatric services were put in place as needed. All staff were able to state in their own words the facility's policy and procedures regarding resident rights and abuse and neglect. All staff were able to describe abuse, neglect, and exploitation, when to report it, and who to report it to. All staff were able to state that residents have the right to have personal items and must give permission for staff to go through their personal items; however, any unsafe items observed would be removed and reported to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for two (Resident #1 and #2) of six residents reviewed for abuse and neglect. The facility failed to protect Resident #1 and #2 from abuse on 05/22/25 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 1:30 PM. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm. Findings included: On 05/28/2025 at 1:11 PM Video footage identified by the DON as having occurred during the incident was reviewed on the DON's cell phone. The residents observed in the video were identified by the DON. The video revealed: 0:10 Resident#2 walking on hallway and enters Resident#1 room. No other staff or residents were observed in view. Min 1:06 Resident#1 appeared to be holding Resident#2 by her neck/head and pushing her out of Residents#1's room, Resident#2 had her hands grabbing Resident#1. The residents hit the wall across the hall from Resident#1's room. Resident#2 fell onto her buttocks, then Resident#1 appeared to hit her head on the wall and fell on top of Resident #2 then rolled to the side. min1:45 CNA F walks into frame. Both residents were observed sitting up. Resident #1 appeared to be holding Resident#2's hands then Resident#2 punched Resident #1 on the face. Resident #1 grabbed Resident#2's hand then the video clip ends. Record review of Resident #1's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Record review of Resident #1's MDS Assessment, dated 03/31/25, reflected she had a BIMS score of 05, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Orthostatic Hypotension(a sudden drop in blood pressure when a person stands up after sitting or lying down), Traumatic Brain Injury(,damage to the brain caused by an external physical force, often a blow or impact to the head) Depression, Bipolar Disorder(a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood to periods of depression), Psychotic Disorder, Insomnia due to mental disorder'. Record review of Resident #1's care plan, initiated 1/30/2025, reflected the following: Focus: 1/30/25- [Resident #1] had a Behavior problem as evidenced by physical aggression towards other resident/ staff, verbally aggressive towards staff and other residents, coming out of the room without clothes on. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Notes reflected the following: 05/22/25 at 9:30PM - The writer heard a loud scuffle, and when the writer looked on the camera the writer observed both residents sitting on the doorway on the floor across from each other. The residents [sic] were immediately separated, and the resident was assisted back into bed. The MD was contacted but has not responded. The DON and administrator were made aware of the incident. The resident daughter (daughters name) was called but did not answer. Writer left a voicemail. This entry was written by LVN B 05/22/2025 10:10PM The writer rounded on the resident and rechecked blood pressure. The resident blood pressure is substantially lower than when the incident happened, and the resident c/o's of a headache, so the resident was sent to the ER for evaluation and treatment. DON and the administrator were notified. This entry was written by LVN B. Record review of Resident #1's hospital records, dated 05/22/25, reflected the following: Patient was a [AGE] year-old female who presents to the Emergency department via EMS due to an assault at 7:00 PM by another pt at her rehab facility. EMS was called a few hours after the assault a night nurse check. She is c/o neck pain and a headache. She is only oriented to self. She was given 1 push dose epi (drug used to treat low blood pressure or heart rate), 4L fluid, 4L of O2 and 5 levophed (drug used to treat severe low blood pressure). She denies smoking and drug usage. Per EMS pt had a blood pressure of systolic 56. Record review of Radiology Results Report, CT spine cervical without contrast dated 05/22/2025 reflected: Right periorbital hematoma (bruising around the eye), Superior endplate fracture suspected at T4(fourth thoracic vertebral body). Record review of Resident #1's History and physical assessment dated [DATE] of the skin reflected small laceration with hematoma on the left orbit. Record review of Resident #2's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] then readmitted [DATE]. Record review of Resident #2's MDS Assessment, dated 02/15/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Depression, anxiety, Altered Mental Status unspecified. Record review of Resident #2's care plan, initiated 11/17/2022, and revised on 05/24/2025 reflected the following: Focus: [Resident #2] Behaviors: has behavior problem OF Wandering, Physical Aggression toward residents, Verbal aggression towards other residents and staff. Interventions include to Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #2's Progress Notes reflected the following: 05/22/2025 10:09PM Note Text: The resident was observed on the floor with another in the hallway. She was assessed for apparent injury; none was noted. The resident was redirected back to the dining area. She does not complain of pain or discomfort and is moving all four extremities at her normal baseline. The provider, DON, administrator, and Resident#2 FM (family members name) were notified. Resident#2s (family members name) not answer, and a voicemail was left to call the facility regarding fall. This entry was written LVN B 05/24/2025 12:50pm Late entry Note Text: Spoke with [NAME], NP, with] COMPANY NAME] regarding resident#2 incident with another resident. No new orders his time. This entry was written by DON. 05/26/2025 8:30PM Resident#2 continues ABT. She was given fluids multiple times this shift. Bruising still visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN G 05/27/2025 03:43 am Note Text: Resident#2 continues ABT TX for UTI. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No sis of pain or distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN H 05/28/2025 04:31 am Note Text: Resident#2 continues PABT TX for UTI day 1/3. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No s/s of distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. Medicated 1 for generalized pain. Nursing will continue to monitor. This entry was entered by LVN H In a phone interview on 05/27/2025at 9:50am with Hospital Social Worker revealed that Residents#1's FM stated that she was confused. When she admitted at the hospital Resident#1 stated that she was assaulted by her boyfriend. Hospital Social Worker stated that Resident #1 also told the nurse that she was assaulted by her baby's father. The Hospital Social Worker stated that Residents# 1 FM stated that after she had the brain injury Resident#1 would make up stories. Hospital Social Worker stated that Resident #1's FM told her that that FM received a call from the nursing home that Resident #1 was in an altercation, and she had black eye. When the Hospital Social Worker met with Resident#1 on 05/23/2025, the resident was talking and answering questions but then she would change her answers. The Hospital Social Worker stated that Resident #1 had a compression fracture of her thoracic spine and that the resident remained admitted at the hospital. In a phone interview on 05/27/2025 at 11:49 AM with Resident #1's FM revealed that the facility left a voicemail on Thursday 5/22/2025 that Resident#1 had gotten in a scuffle with another resident, and she had a black eye. Resident #1's FM stated the next day Friday 05/23/2025 the hospital called the FM and told her that Resident#1 was admitted at the hospital. Resident #1's FM stated that Resident#1 was initially admitted to ICU, but she had been transferred to a regular room. Resident #1's FM stated that Resident#1 right eye was swollen and bruised, and that Resident #1 also had bruises on her arms. Resident #1's FM stated that Resident #1 had been at the facility for over a year. Resident #1's FM stated Resident #1 had gotten into altercations before, but no one was injured. Resident #1's FM stated that when she was at the facility in the past there was no staff watching the residents. Resident #1's FM stated that Resident#1 had a history of a brain injury, and she remembered her name only. Resident #1's FM stated that she called the nursing facility but they never responded to her calls, they called her on Saturday (05/25/25) and the administrator told her that Resident#1 fell and said she was going to do an investigation. Resident #1's FM stated that she told the administrator that the injuries did not look like she fell. Resident #1's FM told the administrator that it was unacceptable they put her daughter's life in jeopardy, and she was not happy at all. In an interview on 05/27/2025 at 10:49AM with LVN A revealed that she has been employed for about 8 month and worked 6am-2 pm Monday through Friday in the Locked unit. LVN A stated that the altercation between Resident #1 and #2 had happened on the evening shift when she was not there. She stated that Resident #1 had a diagnosis of dementia and traumatic brain injury from car accident. LVN A stated that Resident#1 was physically aggressive to residents, staff or to anyone who did not understand what she wanted. LVN A stated that before Resident #1's behavior was controlled, she would agitate other residents like move their food and push other residents. LVN A stated that she spoke to the nurse practitioner who reviewed and adjusted Resident#1's medication and she has had less behaviors. . LVN A stated that there was one CNA and one nurse on the locked unit. LVN A did not feel like the staffing was sufficient based on the needs and supervision of the residents. In an interview on 05/27/2025 at 11:20am with CTA C she said she had been employed for a year and worked in transportation and when she was not taking residents to appointments, she helped in the locked unit. CTA C stated that she was not at the facility when the altercation happened. CTA C stated that sometimes there had been altercations in memory care. In a phone interview on 05/27/2025 at 12:23pm with CNA F revealed that she had been employed for a year and she worked the evening shift from 2-10 pm. CNA F stated that around 7: 30PM she was documenting on the computer at the nurses' station when she heard a scuffle. She noted that Resident#2 who was not on the couch where she had been sleeping. CNA F glanced at the camera, and she saw Resident#1 and Resident#2 on the floor. CNA F stated she separated the two residents while they were still on the floor. CNA F stated that she was the only staff on the unit at the time of the altercation. CNA F stated that nurse (LVN B) told her she had gone to get medication, she was gone for about 15 min to 30 mins. CNA F stated that she wanted the residents to be safe and not fight again. CNA F stated she walked Resident#1 to her room, assisted to her to bed then told Resident#2 to go towards the dining area. CNA F then called the nurse (LVN B) via telephone and reported that she had found the residents on the floor. CNA F stated that at 8pm while doing her rounds she saw the bump on Resident #1's head and the black eye and reported immediately to LVN B. LVN B assessed Resident#1 and made some phone calls then the nurse mentioned that she was going to send Resident#1 to the hospital. CNA F stated that the bump on Resident#1 did not show when she initially separated the residents. CNA F stated that Resident #2 would walk on the hall; she was a high fall risk and could be combative. Resident#1 and Resident#2 had a history of aggression towards each other, and they needed to be separated. CNA F stated that there had been previous altercations between Resident#1 and Resident#2 and the staff separated them to make sure they were safe. CNA F stated that she had been documenting on Residents#2's aggression and refusing care. CNA F stated that Resident#1 showed aggression towards Resident#2 sometimes. CNA F felt that she could manage the unit but with dementia units it would be better to have additional staff because the midst of dealing with the altercation she had another resident who was trying to get up. CNA F stated that the unit was staffed with one CNA and one nurse per shift. CNA F stated sometimes there was only one staff member on the unit, when the other one steps out for lunch. CNA F stated the residents were not one on one care supervision. An attempt on 05/27/2025 at 12:12pm to interview LVN B via telephone was unsuccessful. Second attempt on 05/27/2025 at 12:52PM to interview LVN B via telephone was unsuccessful. A third attempt on 5/27/2025 2:37 PM was made to LVN B via telephone and was unsuccessful. In an interview on 5/27/2025 at 2:13pm with the DON revealed that on 05.22.2025 at around 9 pm she was notified by LVN B, that Resident#1 wandered to Resident#2's room and there was an altercation. The DON stated that she instructed the nurse to document, complete an incident report, notify MD, the resident's family, and administrator. The DON stated that Resident#1 had had aggressive cycles, and they were worse when she was on her monthly periods. The DON stated that Resident#2 had a tendency to agitate other residents but neither Resident #1 nor Resident #2 sought to be aggressive toward each other. The DON stated that Resident#2 wandered and tried to take other residents' belongings which irritated other residents. The DON stated that following the incident LVN B and CNA F had been suspended pending investigation and the other staff had in-serviced on Abuse and neglect, managing resident behavior, and fall precaution. The DON stated that on the locked unit the nurse was to be at the nurse station to monitor the residents in the dining room, and the CNA was to sit on the hallways to watch any resident on the hallway. The DON stated that if the nurse left the unit another nurse was to come and monitor the residents until the nurse returned. She stated the risk to the residents if the unit was left unsupervised was there can be accidents and the residents can be hurt. In a phone interview on 05/27/2025 at 2:43PM with Resident #2's FM revealed that Resident #2 had dementia, she wanders a lot and goes into other residents' rooms. Resident #2's FM stated that she used to get into altercations, but he was not aware of any altercation lately. Resident #2's FM stated that he was at the facility every other day to help feed Resident#2 lunch. Resident #2's FM stated that there was not enough staff to supervise when he was there. In an interview on 05/27/2025 at 4:34 pm with the Administrator revealed that she initially reported the incident as an unwitnessed fall. Administrator stated that LVN B called and said there was a scuffle between Resident #1 and #2, and residents were observed on the floor. Administrator stated when the nurse interviewed Resident#1, the resident said she was hit. Administrator stated the nurse told her there were no injuries. Administrator stated that the nurse called her later and said she was sending Resident#1 to the hospital because her blood pressure had dropped. Administrator stated that the diagnostic report from the hospital showed that there was a T4 fracture, but it wasn't clear if it was new or old. Administrator stated that the hospital admitting diagnosis was hypotension (low blood pressure), but it also mentioned assault, and the resident told the hospital that the family did it. Administrator stated that CNA F said she heard a scuffle and when she looked at the video and she saw Resident#1 and Resident#2 on the floor. The Administrator stated that Resident#2 wanders and had behaviors that could provoke other residents. The Administrator stated that there were always two staff on the locked unit. The Administrator stated she felt that they had sufficient staffing with 10 residents on the locked unit. The Administrator stated that it was okay to have one staff on the unit if the other staff was to leave for a short break as long as there was one staff left in the unit. In an observation and interview on 05/27/2025 at 5:30 PM of Resident#1 at the hospital, revealed she was alert and awake and responded to her name. Resident#1 was observed with large bruising to right eye, bruising to both arms and bruising to her left leg. When asked what happened Resident #1 pointed at her FM and said, she did it. FM was at bedside stated that the resident would not be returning to the facility because the family did not feel like she was going to be safe. In an interview on 05/28/2025 at 8:09 AM with Hospital Case Manager revealed that Resident#1 was admitted with injuries including Right periorbital hematoma, suspected T4 fracture that was undetermined, and it was not being treated, but the resident had orders to follow up with x-rays after discharge. Hospital Case Manager mentioned that the FM did not want the resident to return to the facility. Hospital records requested and provided by staff. Record review of the facility's incidents/accidents report from 03/27/25 to 05/27/25 reflected there were no other situations that involved Resident #1 or Resident #2. Record review of the facility's policy, revised September 2022, and titled Resident to Resident Altercations Reflected: All altercations, including those that may represent resident-to-resident abuse, are investigated, and reported to the nursing supervisor, the director of nursing services and to the administrator. Intervention includes: 1.Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff 2.Behaviors that may provoke a reaction by residents or others include: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating. b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. c. Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing. d. Taking, touching, or rummaging through other's property; and e. Wandering into others' rooms/space. 3.Occurrences of such incidents arc promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. 4.If two residents are involved in an altercation, staff: a. Separate the residents, and institute measures to calm the situation. b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. c. Notify each resident's representative and attending physician of the incident. d. Review the events with the nursing supervisor and director of nursing services and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. e. Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. f. Make any necessary changes in the care plan approaches to any or all of the involved individuals. g. Document in the resident's clinical record all interventions and their effectiveness. h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. Record review of the facility's policy, revised April 2022, Titled Falls and Fall Risk, Managing Reflected: Resident-Centered Approaches to Managing Falls and Fall Risk I. Upon admission, Fall Risk Evaluation will be completed to determine risk for falls. 2.The interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 3.If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4.Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 5.In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 6.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8.ln conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 6/12/2025 at 1:30 PM, due to the above failures. In an interview on 5/29/20205 at 11:30 AM with Regional Nurse Consultant revealed that she had worked for the company for almost three years. Regional Nurse Consultant stated when she came on Saturday 05/24/2025 she did all skin assessments, all safe surveys, and in-serviced the Staff. She stated that she did an assessment on Resident#2 that revealed a small laceration, bruise left eye hematoma on the eyebrow. All bruising's on her forehead were from previous falls. She stated that saw the video footage of the altercation on 05/29/2025. She stated that she wished the altercation did not happen. She stated that the CNA F said the nurse had gone on break and the CNA F was the one that heard the scuffle and intervened and then she told the nurse. She stated that the staffing patterns are always a nurse and one CNA on the memory unit. When the staff left for lunch, there should always be one person on the unit. She stated that she did not feel there was a risk when the incident occurred because the residents were in bed, but dementia residents have a tendency to wander. She stated that the facility was aware that Residnet#1 and Resident#2 had behaviors. Resident#2 was the typical dementia patient, she would wander and get into stuff, she doesn't purposely seek to attack a person. Resident#1 was more alert than Resident#2 she was able to respond to questions and communicate. She stated that things are going to happen on the dementia units. She did not think there was an immediacy because interventions have been put in place to show that the facility was going to mitigate any further incidents. Resident#2 was put on one-on-one monitoring to prevent her from wandering and going into other residents' rooms. She stated that the facility added 12 hours for supervision in the memory unit during peak hours, from 7am to 7pm, because most of the residents go to bed early and staff were to take lunch and breaks while that additional staff was present. On 5/29/2025 at 1:15PM an interview with DON revealed that the one nurse and one CNA was sufficient because they had 10 residents in the locked unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there. She stated that on the evening shift the nurses from upfront go back there to help. The charge nurses were responsible to ensure the unit was covered. If there is an issue getting someone back there, they let me know. It was always one nurse and one CNA. On the male unit there was one nurse and two CNAs because there were 20 residents. The DON stated that she had not been able to contact LVN B. The DON stated that LVN B had no disciplinary action Interview on 05/29/2025 at 1:10PM with the Administrator revealed that she did not know how long LVN B was gone from the unit when the altercation happened. She stated that peak hours will be from 7am to 7 pm because those are the most active hours. She stated that when the altercation happened the one staff was sufficient to intervene because the unit was calm and most residents were in bed. The facility POR for immediate jeopardy was accepted and on 05/29/25 at 9:49AM and reflected the following: Identify residents who could be affected. All Residents on the unit have the potential to be affected. The Facility census on 05/28/25 on the memory care unit was 11. Resident #1 was sent to the hospital for evaluation on 5/22/25 by Physician and remains in the hospital. Identify what action was taken to prevent further abuse: Resident #2 was placed on one-to-one monitoring on 5/24/25 on the 6/2 shift. Resident #2 was evaluated by psychiatry services on 05/26/25 with no new recommendations issued. Upon readmission, Resident #1 will be evaluated by psychiatry, and any new recommendations will be initiated. Nurse Consultant conducted 100% resident rounds on the unit to determine if further allegations of abuse were made. This was completed on 05/28/25. Safe surveys were conducted on the unit on 5/24/25 by Nurse Consultant. A skin sweep was completed by the Nurse Consultant on 05/24/25 with no additional findings. The Administrator reviewed the results of the completed safe surveys and skin sweep with no additional findings on 05/28/25. An additional 12 hours of staff will be added to the staffing pattern to allow for additional supervision of the residents during peak hours. This will be initiated on 5/29/25. The DON/Designee will be responsible for monitoring the new staffing pattern. The Nurse and Aide who worked the unit on 5/22/25 were suspended on 5/23/25 pending further investigation. In-Service conducted. The Abuse Coordinator and DON were educated on 05/28/25 by the Nurse Consultant on how to investigate suspicions of abuse and the importance of thorough investigation and interventions to prevent Abuse/Neglect and supervision to prevent resident-to-resident altercations. In-service was conducted by the Administrator/ADON on Managing Aggressive Behavior. Beginning on 5/23/25, [psychology services company name] provided additional training on de-escalation techniques, which was completed on 5/28/25. In-servicing was initiated by Administrator/DON on Abuse investigation, interventions, and completion of Incident Reports beginning 05/25/25 and completed on 5/28/25. In-service will be provided to all staff on Immediate Notification of Allegations to the Facility Abuse Coordinator or designee when not in a facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse, Neglect, and Misappropriation, and notification of proper local and state entities by DON and ADON. Agency staff who work in the facility or staff on PTO or LOA will have in-service training completed prior to working the floor by the DON/Designee. The DON/Designee will in-service the staffing coordinator and unit nurses regarding the new staffing pattern. Abuse and Neglect training will be a part of the new hire orientation, effective immediately, and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse, and resident protection from abuse/neglect. This will be completed at the time of hire by HR/DON and verified by the Administrator. Any resident who is deemed an imminent threat to others will be placed on one-to-one monitoring until alternate placement can be arranged or the threat is no longer viable. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 05/29/25 at 10:46 AM to 4:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN A, LVN G, LVN N , CTA C, CNA D, CNA E, CNA F, CNA L, CNA M, CNA K, RN I, RN J, Receptionist, housekeeping, DON, and the Administrator. Record review of a QAPI Agenda, dated 05/28/25, reflected Administrator and DON were in attendance. Record review of in-service sign in sheets, dated 05/24/25, and titled Accidents and Incident and Resident to Resident altercation reflected both the DON and Administrator had signed. Record review of Accident and Incidents - Investigating and Reporting in-service dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of Resident-to-Resident Altercations in-service, dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of a Falls and Fall Risk Managing in-service, dated 05/23/25 - 05/28/2025 reflected 95 staff had been in-serviced. Record review of an in-service sign in sheets, dated 05/28/25, and titled Reporting and Investigation of Abuse and Neglect Managing Difficult behavior Supervision and Preventing Abuse reflected both the DON and Administrator had signed. 5/29/2025 12:13 PM Observed Resident#2's FM assisting Resident #2 with lunch tray. Resident#2 appeared well groomed, calm, and followed direction. Resident#2's FM stated that the bruises on her face were from previous falls and that psychiatrist had discontinued some of Resident#2's medication after her last hospitalization. 5/29/2025 12:08 PM interview with LVN A revealed that there were 11 residents in the unit. The unit was staffed with one nurse and two CNAs. She stated that is she had requested to have additional staff on the unit. She stated that when she left the unit to clock out, she notified CNA. She stated that Resident#1 and Resident#2 did not get along and she kept them separated in the daytime because they used to fight over the couch, so LVN A moved the couch and got two separated chairs. 5/29/2025 4:20pm Interview with on-call physician cove[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 residents (Resident #1 and #2) of 6 residents reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 and Resident #2 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 5:05pm. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of severe injury, hospitalization, and decline in quality of life. Findings included: On 05/28/2025 at 1:11 PM Video footage identified by the DON as having occurred during the incident was reviewed on the DON's cell phone. The residents observed in the video were identified by the DON. The video revealed: 0:10 Resident#2 walking on hallway and enters Resident#1 room. No other staff or residents were observed in view. Min 1:06 Resident#1 appeared to be holding Resident#2 by her neck/head and pushing her out of Residents#1's room, Resident#2 had her hands grabbing Resident#1. The residents hit the wall across the hall from Resident#1's room. Resident#2 fell onto her buttocks, then Resident#1 appeared to hit her head on the wall and fell on top of Resident #2 then rolled to the side. min1:45 CNA F walks into frame. Both residents were observed sitting up. Resident #1 appeared to be holding Resident#2's hands then Resident#2 punched Resident #1 on the face. Resident #1 grabbed Resident#2's hand then the video clip ends. Record review of Resident #1's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Record review of Resident #1's MDS Assessment, dated 03/31/25, reflected she had a BIMS score of 05, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Orthostatic Hypotension(a sudden drop in blood pressure when a person stands up after sitting or lying down), Traumatic Brain Injury(,damage to the brain caused by an external physical force, often a blow or impact to the head) Depression, Bipolar Disorder(a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood to periods of depression), Psychotic Disorder, Insomnia due to mental disorder'. Record review of Resident #1's care plan, initiated 1/30/2025, reflected the following: Focus: 1/30/25- [Resident #1] had a Behavior problem as evidenced by physical aggression towards other resident/ staff, verbally aggressive towards staff and other residents, coming out of the room without clothes on. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Notes reflected the following: 05/22/25 at 9:30PM - The writer heard a loud scuffle, and when the writer looked on the camera the writer observed both residents sitting on the doorway on the floor across from each other. The residents [sic] were immediately separated, and the resident was assisted back into bed. The MD was contacted but has not responded. The DON and administrator were made aware of the incident. The resident daughter (daughters name) was called but did not answer. Writer left a voicemail. This entry was written by LVN B 05/22/2025 10:10PM The writer rounded on the resident and rechecked blood pressure. The resident blood pressure is substantially lower than when the incident happened, and the resident c/o's of a headache, so the resident was sent to the ER for evaluation and treatment. DON and the administrator were notified. This entry was written by LVN B. Record review of Resident #1's hospital records, dated 05/22/25, reflected the following: Patient was a [AGE] year-old female who presents to the Emergency department via EMS due to an assault at 7:00 PM by another pt at her rehab facility. EMS was called a few hours after the assault a night nurse check. She is c/o neck pain and a headache. She is only oriented to self. She was given 1 push dose epi (drug used to treat low blood pressure or heart rate), 4L fluid, 4L of O2 and 5 levophed (drug used to treat severe low blood pressure). She denies smoking and drug usage. Per EMS pt had a blood pressure of systolic 56. Record review of Radiology Results Report, CT spine cervical without contrast dated 05/22/2025 reflected: Right periorbital hematoma (bruising around the eye), Superior endplate fracture suspected at T4(fourth thoracic vertebral body). Record review of Resident #1's History and physical assessment dated [DATE] of the skin reflected small laceration with hematoma on the left orbit. Record review of Resident #2's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] then readmitted [DATE]. Record review of Resident #2's MDS Assessment, dated 02/15/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Depression, anxiety, Altered Mental Status unspecified. Record review of Resident #2's care plan, initiated 11/17/2022, and revised on 05/24/2025 reflected the following: Focus: [Resident #2] Behaviors: has behavior problem OF Wandering, Physical Aggression toward residents, Verbal aggression towards other residents and staff. Interventions include to Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #2's Progress Notes reflected the following: 05/22/2025 10:09PM Note Text: The resident was observed on the floor with another in the hallway. She was assessed for apparent injury; none was noted. The resident was redirected back to the dining area. She does not complain of pain or discomfort and is moving all four extremities at her normal baseline. The provider, DON, administrator, and Resident#2 FM (family members name) were notified. Resident#2s (family members name) not answer, and a voicemail was left to call the facility regarding fall. This entry was written LVN B 05/24/2025 12:50pm Late entry Note Text: Spoke with [NAME], NP, with] COMPANY NAME] regarding resident#2 incident with another resident. No new orders his time. This entry was written by DON. 05/26/2025 8:30PM Resident#2 continues ABT. She was given fluids multiple times this shift. Bruising still visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN G 05/27/2025 03:43 am Note Text: Resident#2 continues ABT TX for UTI. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No sis of pain or distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN H 05/28/2025 04:31 am Note Text: Resident#2 continues PABT TX for UTI day 1/3. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No s/s of distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. Medicated 1 for generalized pain. Nursing will continue to monitor. This entry was entered by LVN H In a phone interview on 05/27/2025at 9:50am with Hospital Social Worker revealed that Residents#1's FM stated that she was confused. When she admitted at the hospital Resident#1 stated that she was assaulted by her boyfriend. Hospital Social Worker stated that Resident #1 also told the nurse that she was assaulted by her baby's father. The Hospital Social Worker stated that Residents# 1 FM stated that after she had the brain injury Resident#1 would make up stories. Hospital Social Worker stated that Resident #1's FM told her that that FM received a call from the nursing home that Resident #1 was in an altercation, and she had black eye. When the Hospital Social Worker met with Resident#1 on 05/23/2025, the resident was talking and answering questions but then she would change her answers. The Hospital Social Worker stated that Resident #1 had a compression fracture of her thoracic spine and that the resident remained admitted at the hospital. In a phone interview on 05/27/2025 at 11:49 AM with Resident #1's FM revealed that the facility left a voicemail on Thursday 5/22/2025 that Resident#1 had gotten in a scuffle with another resident, and she had a black eye. Resident #1's FM stated the next day Friday 05/23/2025 the hospital called the FM and told her that Resident#1 was admitted at the hospital. Resident #1's FM stated that Resident#1 was initially admitted to ICU, but she had been transferred to a regular room. Resident #1's FM stated that Resident#1 right eye was swollen and bruised, and that Resident #1 also had bruises on her arms. Resident #1's FM stated that Resident #1 had been at the facility for over a year. Resident #1's FM stated Resident #1 had gotten into altercations before, but no one was injured. Resident #1's FM stated that when she was at the facility in the past there was no staff watching the residents. Resident #1's FM stated that Resident#1 had a history of a brain injury, and she remembered her name only. Resident #1's FM stated that she called the nursing facility but they never responded to her calls, they called her on Saturday (05/25/25) and the administrator told her that Resident#1 fell and said she was going to do an investigation. Resident #1's FM stated that she told the administrator that the injuries did not look like she fell. Resident #1's FM told the administrator that it was unacceptable they put her daughter's life in jeopardy, and she was not happy at all. In an interview on 05/27/2025 at 10:49AM with LVN A revealed that she has been employed for about 8 month and worked 6am-2 pm Monday through Friday in the Locked unit. LVN A stated that the altercation between Resident #1 and #2 had happened on the evening shift when she was not there. She stated that Resident #1 had a diagnosis of dementia and traumatic brain injury from car accident. LVN A stated that Resident#1 was physically aggressive to residents, staff or to anyone who did not understand what she wanted. LVN A stated that before Resident #1's behavior was controlled, she would agitate other residents like move their food and push other residents. LVN A stated that she spoke to the nurse practitioner who reviewed and adjusted Resident#1's medication and she has had less behaviors. . LVN A stated that there was one CNA and one nurse on the locked unit. LVN A did not feel like the staffing was sufficient based on the needs and supervision of the residents. In an interview on 05/27/2025 at 11:20am with CTA C she said she had been employed for a year and worked in transportation and when she was not taking residents to appointments, she helped in the locked unit. CTA C stated that she was not at the facility when the altercation happened. CTA C stated that sometimes there had been altercations in memory care. In a phone interview on 05/27/2025 at 12:23pm with CNA F revealed that she had been employed for a year and she worked the evening shift from 2-10 pm. CNA F stated that around 7: 30PM she was documenting on the computer at the nurses' station when she heard a scuffle. She noted that Resident#2 who was not on the couch where she had been sleeping. CNA F glanced at the camera, and she saw Resident#1 and Resident#2 on the floor. CNA F stated she separated the two residents while they were still on the floor. CNA F stated that she was the only staff on the unit at the time of the altercation. CNA F stated that nurse (LVN B) told her she had gone to get medication, she was gone for about 15 min to 30 mins. CNA F stated that she wanted the residents to be safe and not fight again. CNA F stated she walked Resident#1 to her room, assisted to her to bed then told Resident#2 to go towards the dining area. CNA F then called the nurse (LVN B) via telephone and reported that she had found the residents on the floor. CNA F stated that at 8pm while doing her rounds she saw the bump on Resident #1's head and the black eye and reported immediately to LVN B. LVN B assessed Resident#1 and made some phone calls then the nurse mentioned that she was going to send Resident#1 to the hospital. CNA F stated that the bump on Resident#1 did not show when she initially separated the residents. CNA F stated that Resident #2 would walk on the hall; she was a high fall risk and could be combative. Resident#1 and Resident#2 had a history of aggression towards each other, and they needed to be separated. CNA F stated that there had been previous altercations between Resident#1 and Resident#2 and the staff separated them to make sure they were safe. CNA F stated that she had been documenting on Residents#2's aggression and refusing care. CNA F stated that Resident#1 showed aggression towards Resident#2 sometimes. CNA F felt that she could manage the unit but with dementia units it would be better to have additional staff because the midst of dealing with the altercation she had another resident who was trying to get up. CNA F stated that the unit was staffed with one CNA and one nurse per shift. CNA F stated sometimes there was only one staff member on the unit, when the other one steps out for lunch. CNA F stated the residents were not one on one care supervision. An attempt on 05/27/2025 at 12:12pm to interview LVN B via telephone was unsuccessful. Second attempt on 05/27/2025 at 12:52PM to interview LVN B via telephone was unsuccessful. A third attempt on 5/27/2025 2:37 PM was made to LVN B via telephone and was unsuccessful. In an interview on 5/27/2025 at 2:13pm with the DON revealed that on 05.22.2025 at around 9 pm she was notified by LVN B, that Resident#1 wandered to Resident#2's room and there was an altercation. The DON stated that she instructed the nurse to document, complete an incident report, notify MD, the resident's family, and administrator. The DON stated that Resident#1 had had aggressive cycles, and they were worse when she was on her monthly periods. The DON stated that Resident#2 had a tendency to agitate other residents but neither Resident #1 nor Resident #2 sought to be aggressive toward each other. The DON stated that Resident#2 wandered and tried to take other residents' belongings which irritated other residents. The DON stated that following the incident LVN B and CNA F had been suspended pending investigation and the other staff had in-serviced on Abuse and neglect, managing resident behavior, and fall precaution. The DON stated that on the locked unit the nurse was to be at the nurse station to monitor the residents in the dining room, and the CNA was to sit on the hallways to watch any resident on the hallway. The DON stated that if the nurse left the unit another nurse was to come and monitor the residents until the nurse returned. She stated the risk to the residents if the unit was left unsupervised was there can be accidents and the residents can be hurt. In a phone interview on 05/27/2025 at 2:43PM with Resident #2's FM revealed that Resident #2 had dementia, she wanders a lot and goes into other residents' rooms. Resident #2's FM stated that she used to get into altercations, but he was not aware of any altercation lately. Resident #2's FM stated that he was at the facility every other day to help feed Resident#2 lunch. Resident #2's FM stated that there was not enough staff to supervise when he was there. In an interview on 05/27/2025 at 4:34 pm with the Administrator revealed that she initially reported the incident as an unwitnessed fall. Administrator stated that LVN B called and said there was a scuffle between Resident #1 and #2, and residents were observed on the floor. Administrator stated when the nurse interviewed Resident#1, the resident said she was hit. Administrator stated the nurse told her there were no injuries. Administrator stated that the nurse called her later and said she was sending Resident#1 to the hospital because her blood pressure had dropped. Administrator stated that the diagnostic report from the hospital showed that there was a T4 fracture, but it wasn't clear if it was new or old. Administrator stated that the hospital admitting diagnosis was hypotension (low blood pressure), but it also mentioned assault, and the resident told the hospital that the family did it. Administrator stated that CNA F said she heard a scuffle and when she looked at the video and she saw Resident#1 and Resident#2 on the floor. The Administrator stated that Resident#2 wanders and had behaviors that could provoke other residents. The Administrator stated that there were always two staff on the locked unit. The Administrator stated she felt that they had sufficient staffing with 10 residents on the locked unit. The Administrator stated that it was okay to have one staff on the unit if the other staff was to leave for a short break as long as there was one staff left in the unit. In an observation and interview on 05/27/2025 at 5:30 PM of Resident#1 at the hospital, revealed she was alert and awake and responded to her name. Resident#1 was observed with large bruising to right eye, bruising to both arms and bruising to her left leg. When asked what happened Resident #1 pointed at her FM and said, she did it. FM was at bedside stated that the resident would not be returning to the facility because the family did not feel like she was going to be safe. In an interview on 05/28/2025 at 8:09 AM with Hospital Case Manager revealed that Resident#1 was admitted with injuries including Right periorbital hematoma, suspected T4 fracture that was undetermined, and it was not being treated, but the resident had orders to follow up with x-rays after discharge. Hospital Case Manager mentioned that the FM did not want the resident to return to the facility. Hospital records requested and provided by staff. Record review of the facility's incidents/accidents report from 03/27/25 to 05/27/25 reflected there were no other situations that involved Resident #1 or Resident #2. Record review of the facility's policy, revised September 2022, and titled Resident to Resident Altercations Reflected: All altercations, including those that may represent resident-to-resident abuse, are investigated, and reported to the nursing supervisor, the director of nursing services and to the administrator. Intervention includes: 1.Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff 2.Behaviors that may provoke a reaction by residents or others include: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating. b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. c. Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing. d. Taking, touching, or rummaging through other's property; and e. Wandering into others' rooms/space. 3.Occurrences of such incidents arc promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. 4.If two residents are involved in an altercation, staff: a. Separate the residents, and institute measures to calm the situation. b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. c. Notify each resident's representative and attending physician of the incident. d. Review the events with the nursing supervisor and director of nursing services and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. e. Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. f. Make any necessary changes in the care plan approaches to any or all of the involved individuals. g. Document in the resident's clinical record all interventions and their effectiveness. h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. Record review of the facility's policy, revised April 2022, Titled Falls and Fall Risk, Managing Reflected: Resident-Centered Approaches to Managing Falls and Fall Risk I. Upon admission, Fall Risk Evaluation will be completed to determine risk for falls. 2.The interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 3.If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4.Examples of initial approaches might include exercise and balance training, a rearrangement of room fur-niture, improving footwear, changing the lighting, etc. 5.In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 6.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8.ln conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/28/2025 at 4:48PM, due to the above failures and the IJ Templated was provided at 5:00PM. In an interview on 5/29/20205 at 11:30 AM with Regional Nurse Consultant revealed that she had worked for the company for almost three years. Regional Nurse Consultant stated when she came on Saturday 05/24/2025 she did all skin assessments, all safe surveys, and in-serviced the Staff. She stated that she did an assessment on Resident#2 that revealed a small laceration, bruise left eye hematoma on the eyebrow. All bruising's on her forehead were from previous falls. She stated that saw the video footage of the altercation on 05/29/2025. She stated that she wished the altercation did not happen. She stated that the CNA F said the nurse had gone on break and the CNA F was the one that heard the scuffle and intervened and then she told the nurse. She stated that the staffing patterns are always a nurse and one CNA on the memory unit. When the staff left for lunch, there should always be one person on the unit. She stated that she did not feel there was a risk when the incident occurred because the residents were in bed, but dementia residents have a tendency to wander. She stated that the facility was aware that Residnet#1 and Resident#2 had behaviors. Resident#2 was the typical dementia patient, she would wander and get into stuff, she doesn't purposely seek to attack a person. Resident#1 was more alert than Resident#2 she was able to respond to questions and communicate. She stated that things are going to happen on the dementia units. She did not think there was an immediacy because interventions have been put in place to show that the facility was going to mitigate any further incidents. Resident#2 was put on one-on-one monitoring to prevent her from wandering and going into other residents' rooms. She stated that the facility added 12 hours for supervision in the memory unit during peak hours, from 7am to 7pm, because most of the residents go to bed early and staff were to take lunch and breaks while that additional staff was present. On 5/29/2025 at 1:15PM an interview with DON revealed that the one nurse and one CNA was sufficient because they had 10 residents in the locked unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there. She stated that on the evening shift the nurses from upfront go back there to help. The charge nurses were responsible to ensure the unit was covered. If there is an issue getting someone back there, they let me know. It was always one nurse and one CNA. On the male unit there was one nurse and two CNAs because there were 20 residents. The DON stated that she had not been able to contact LVN B. The DON stated that LVN B had no disciplinary action Interview on 05/29/2025 at 1:10PM with the Administrator revealed that she did not know how long LVN B was gone from the unit when the altercation happened. She stated that peak hours will be from 7am to 7 pm because those are the most active hours. She stated that when the altercation happened the one staff was sufficient to intervene because the unit was calm and most residents were in bed. The facility POR for immediate jeopardy was accepted and on 05/29/25 at 9:49AM and reflected the following: Identify residents who could be affected. All Residents on the unit have the potential to be affected. The Facility census on 05/28/25 on the memory care unit was 11. Resident #1 was sent to the hospital for evaluation on 5/22/25 by Physician and remains in the hospital. Identify what action was taken to prevent further abuse: Resident #2 was placed on one-to-one monitoring on 5/24/25 on the 6/2 shift. Resident #2 was evaluated by psychiatry services on 05/26/25 with no new recommendations issued. Upon readmission, Resident #1 will be evaluated by psychiatry, and any new recommendations will be initiated. Nurse Consultant conducted 100% resident rounds on the unit to determine if further allegations of abuse were made. This was completed on 05/28/25. Safe surveys were conducted on the unit on 5/24/25 by Nurse Consultant. A skin sweep was completed by the Nurse Consultant on 05/24/25 with no additional findings. The Administrator reviewed the results of the completed safe surveys and skin sweep with no additional findings on 05/28/25. An additional 12 hours of staff will be added to the staffing pattern to allow for additional supervision of the residents during peak hours. This will be initiated on 5/29/25. The DON/Designee will be responsible for monitoring the new staffing pattern. The Nurse and Aide who worked the unit on 5/22/25 were suspended on 5/23/25 pending further investigation. In-Service conducted. The Abuse Coordinator and DON were educated on 05/28/25 by the Nurse Consultant on how to investigate suspicions of abuse and the importance of thorough investigation and interventions to prevent Abuse/Neglect and supervision to prevent resident-to-resident altercations. In-service was conducted by the Administrator/ADON on Managing Aggressive Behavior. Beginning on 5/23/25, [psychology services company name] provided additional training on de-escalation techniques, which was completed on 5/28/25. In-servicing was initiated by Administrator/DON on Abuse investigation, interventions, and completion of Incident Reports beginning 05/25/25 and completed on 5/28/25. In-service will be provided to all staff on Immediate Notification of Allegations to the Facility Abuse Coordinator or designee when not in a facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse, Neglect, and Misappropriation, and notification of proper local and state entities by DON and ADON. Agency staff who work in the facility or staff on PTO or LOA will have in-service training completed prior to working the floor by the DON/Designee. The DON/Designee will in-service the staffing coordinator and unit nurses regarding the new staffing pattern. Abuse and Neglect training will be a part of the new hire orientation, effective immediately, and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse, and resident protection from abuse/neglect. This will be completed at the time of hire by HR/DON and verified by the Administrator. Any resident who is deemed an imminent threat to others will be placed on one-to-one monitoring until alternate placement can be arranged or the threat is no longer viable. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 05/29/25 at 10:46 AM to 4:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN A, LVN G, LVN N , CTA C, CNA D, CNA E, CNA F, CNA L, CNA M, CNA K, RN I, RN J, Receptionist, housekeeping, DON, and the Administrator. Record review of a QAPI Agenda, dated 05/28/25, reflected Administrator and DON were in attendance. Record review of in-service sign in sheets, dated 05/24/25, and titled Accidents and Incident and Resident to Resident altercation reflected both the DON and Administrator had signed. Record review of Accident and Incidents - Investigating and Reporting in-service dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of Resident-to-Resident Altercations in-service, dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of a Falls and Fall Risk Managing in-service, dated 05/23/25 - 05/28/2025 reflected 95 staff had been in-serviced. Record review of an in-service sign in sheets, dated 05/28/25, and titled Reporting and Investigation of Abuse and Neglect Managing Difficult behavior Supervision and Preventing Abuse reflected both the DON and Administrator had signed. 5/29/2025 12:13 PM Observed Resident#2's FM assisting Resident #2 with lunch tray. Resident#2 appeared well groomed, calm, and followed direction. Resident#2's FM stated that the bruises on her face were from previous falls and that psychiatrist had discontinued some of Resident#2's medication after her last hospitalization. 5/29/2025 12:08 PM interview with LVN A revealed that there were 11 residents in the unit. The unit was staffed with one nurse and two CNAs. She stated that is she had requested to have additional staff on the unit. She stated that when she left the unit to clock out, she notified CNA. She stated that Resident#1 and Resident#2 did not get along and she kept them separated in the daytime because they used to fight over t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify consistent with his or her authority, the resident representative when there was a change in the resident's physical, mental, or psychosocial status for 1 resident (Resident #1) of 9 residents reviewed for notification of change of condition. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of increased pain, infections, development of new pressure ulcers, and decline in quality of life and serious harm for residents. Findings included: Record review of Resident #1's face sheet dated 04/23/2024 indicated an [AGE] year-old female initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (mile cognitive impairment), congestive heart failure (heart does not bump blood enough to meet the body's needs), hypertension (pressure in blood vessels is too high), and Type 2 diabetes (problems in the way the body regulates and uses sugar as fuel). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 4, indicating severe cognitive impairment. Resident #1 required supervision for eating, substantial/maximal assistance with toileting and personal hygiene, and dependent for transfer. She was always incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers/injuries, she did not have any unhealed pressure ulcers/injuries but had moisture associated skin damage - treatments include applications of ointments/medications. Record review of Resident #1's Comprehensive Care Plan dated 03/14/2024 reflected, [Resident #1] has an ADL self-care performance deficit r/t impaired gait2/balance, poor comprehension r/t Dementia/Alzheimer's, revised on 03/25/2024. Interventions included extensive to total x 2 for bed mobility, transfers, dressing, and toileting. [Resident #1] has actual impairment to skin integrity of the peri area r/t incontinence. Interventions: Triad cream per family request, initiated 04/04/2024. Record review of Resident #1's March 2024 Nursing MAR reflected Preventative Skin Care: Apply Moisture Barrier every shift and PRN. Start Date - 03/29/2024. D/C Date - 03/28/2024. Record review of Resident #1's March 2024 TAR did not reflect treatment orders. Record review of Resident #1's April 2024 Nursing MAR and TAR did not reflect treatment orders. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. The site(s), type, measurements, or stage were not identified. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. An unmeasured pressure wound was identified to the left and right buttocks. An unmeasured open area was identified to the Coccyx. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Wound Progress note 04/21/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the notified RP and date were blank. The physician was notified 04/21/24. The wound type was other and the location reflected wound has deteriorated rapidly in the past 2 days; Heavy exudate (drainage that seeps out of wounds); an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 9 cm x 10 cm x 0.5 cm. Additional Comments: WOUND HAS DETERIORATED LOOKS LIKE ABSCESS. Doctor notified with orders for wound care ASAP. In an interview on 04/23/2024 at 11:25 AM, ADON B stated she was the Wound Care Nurse. She said when Resident #1 admitted to the facility on [DATE], she did not have any wounds. She said Resident #1 was sent to the hospital for a UTI and returned to the facility on [DATE] with two small open wounds on her right and left buttocks. She said the family wanted them treated with cream they brought in because that seemed to help in the past. She said she did not consult the MD or Wound Care Doctor about the wounds because she attributed them to moisture related and only warranted barrier cream. She stated she completed Resident #1's wound care daily and the wound did not get better or worse. She said on 04/04/2024 she started pursuit of having the family sign a consent form to see the Wound Care Doctor because Resident #1 did not get out of bed and the wounds were not getting better. She said she did not consult with the Wound care Doctor because they would not see Resident #1 without a consent. She said she was able to have the family complete the consent on 04/08/2024 but the Wound care Doctor had already rounded for the day and did not see Resident #1. She said she had not discussed Resident #1 with the Wound Care Doctor on 04/08/2024 because she did not have the consent signed until after the Doctor left the facility. She said she was not aware that LVN A had documented the development of another wound on Resident #1's sacrum, during a skin assessment on 04/11/2024. She said the Wound care Doctor was next in the facility on 04/15/2024 but she was late on that day and was not able to provide the consent to the Doctor, therefore the Doctor, did not see Resident #1's wounds again. She stated she last saw Resident #1's wounds on 04/18/2024 and they looked normal to her. She said she worked on 04/21/2024 and LVN E called her to look at Resident #1's wound. She said it deteriorated a lot and seemed to have an abscess and measured 9 cm x 10 cm x 0.5 cm. She stated the MD was notified by LVN E and the MD told them to clean and dress the wound and referred to the WCD on 04/22/2024. She said she had not consulted with the MD or the WCD about Resident #1's wounds until 04/22/2024 when the Wound Care Doctor sent Resident #1 to the hospital for possible debridement. ADON A stated she did wound care daily, which included applying cream to the wound and dressing it, Monday through Friday and the nurses followed up with wound care on the weekends. She said it was important to follow doctor's orders for wound care, but the family only wanted triad cream applied to the wound. She said she should have consulted the WCD on 04/04/2024 when she initially felt Resident #1 should be seen by the WCD. In an interview on 04/23/2024 at 12:33 PM, the DON stated, Resident #1 returned to the facility on [DATE] from the hospital with an opening (sheer) on the sacrum. She stated the family only wanted the wound to be treated with cream. She said the family was to sign a consent for Resident #1 to see the WCD and did on 04/08/2024 after the WCD had already left the facility. She said the facility needed a consent for residents to see the WCD but not to consult with them. She said the next time the WCD was in the facility on 04/15/24, the WCN was late, and they missed each other. Resident #1 was not seen by the WCD. She said the WCN should have discussed the wound with the WCD or MD to get treatment orders in place. She said she needed to put a system in place for someone else to round with the WCD in the WCN's absence. She said on 04/22/2024, RN G called her to tell her about Resident #1's wound. She said LVN E called the MD and was instructed to clean and dress the wound and refer to the WCD the next day, 04/22/2024. She said Resident #1 was sent to the hospital on by the WCD on 04/22/24. She said she expected nursing staff to follow the facility's policy and ensure they consulted the physician when changes in skin are noted. She said she expected staff to obtain and follow treatment order for all wounds. In a telephone interview on 04/23/2024 at 1:38 PM, the WCD stated she did not see residents unless there was a referral and consent completed. She said she knew the WCN was getting a consent from the facility but had not discussed the wounds with her. She said she came to the facility every Monday and on 04/15/2024 Resident #1 was not on her list of residents to see. She said the WCN was not there that day. She said the WCN provided the consents and list of residents to see. She said she would like to be notified and consulted of wound changes for all residents because wounds can deteriorate quickly. She said all wounds should have treatment orders in place if not from the WCD then from the MD. In an interview on 04/23/2024 at 1:46 PM, CNA D stated when Resident #1 returned to the facility from the hospital on [DATE], she had a small opening on her bottom and the family wanted them to use cream to treat it. She said they placed signage on the walls directing this. She said she worked with Resident #1 on 04/10/2024 and again on 04/17/2024 and 04/18/2024 the wound looked the same. She said she worked with Resident #1 on 04/22/2024 and the wound looked like it burst and was huge. In an interview on 04/23/2024 at 1:53 PM, LVN C stated she sent Resident #1 to the hospital on [DATE] by the WCD. She said the wound had grown, was very deep and the skin was all gone. She said it had not been like that last week. She said she had not been notified that it had worsened. An observation on 04/23/2024 at 4:15 PM at the hospital, of Resident #1 revealed her sleeping. She was propped on her side with wedges. In an interview on 04/23/2024 at 4:20 PM, Family Member O stated Resident #1 returned to the facility from the hospital on [DATE]. She said Resident #1's wound was about the size of a quarter and not deep or oozing but it was a little red. She said she brought cream to the facility for them to use on the wound because that seemed to help in the past. She said the WCN did not ask her to sign a consent for Resident #1 to see the WCD until 04/08/2024 and it was provided immediately. She said on 04/21/2024 the facility called her and said the wound had gotten larger and started oozing. She said the WCD saw Resident #1 on 04/22/2024 and sent her to the hospital. She said Resident #1 had surgery to remove infection. In an interview on 04/23/2024 at 4:30 PM, Hospital RN P said Resident #1 had debridement surgery this morning. She said there was an ulcer under the wound which burst and revealed deep tissue damage. She said they used wedges to position Resident #1 on her side and they alternate every 2 hours. In an interview on 04/26/2024 at 2:10 PM, LVN A stated she did the readmission assessment for Resident #1 when she returned to the facility on [DATE]. She said Resident #1 did have open areas on her buttocks. She said the top layer of skin was off. She said the family wanted to use cream on the wound and she entered that into the orders. She said she had not consulted with the MD about the cream treatment. She said when she did the skin assessment on 04/11/2024, an additional wound was on the coccyx. She said the MD should be informed of all wound changes and treatment orders requested. In an interview on 04/26/2024 at 2:49 PM, ADON B stated - she did not open the weekly skin assessments but used the report to identify new wounds and follow up, she said she would let the MD know about new wounds and request treatment orders then enter them into the clinical record. She said she did not do that for Resident #1 because the family only wanted the use of cream. She said she followed up with wounds as best she could but often had to work as a floor nurse. She said the risk to residents of not consulting the MD or WCD could result in new or worsening wounds. In a telephone interview on 04/26/2024 at 3:28 PM, LVN E stated, she called RN G on 04/20/2024 about Resident #1's deteriorating wound and informed her there were no wound treatment orders in the clinical record. She said RN G contacted the DON and they told her the family was aware of the wound and only wanted cream as treatments. She said the wound on Resident #1's right buttock was open and not as deep as the wound on the left buttocks and there was not drainage. LVN E said on 04/21/2024, Resident #1's wound was worse and developed some odor and drainage. LVN E said she notified the MD who instructed her to clean and dress the wound then refer to the WCD on 04/22/2024. In an interview on 04/26/2024 at 3:28 PM, ADON F stated when the WCN was not available nursing staff typically called her to round with the WCD. She said all treatments needed to be order and nurses needed to follow doctor's order. She said she expected skin assessments to be completed weekly and documented in the clinical record. She said if there were changes they needed to be noted in the 24-hour report for follow up. In an interview on 04/26/2024 at 3:28 PM, RN G stated, LVN E called her on 04/20/2024 to inform her that Resident #1 did not have wound treatment orders in place. She said she asked the WCN who told her the family only wanted the wound treated with cream they brought from home. She said it did not make sense to her and called the DON who told her the same thing. She said the WCD should have seen Resident #1 on their next visit to the facility on [DATE]. She said there was not documentation that the MD or WCD had seen the wound or that treatment orders were requested. She said not consulting the MD or requesting treatment orders placed Residents at risk of worsening wounds and harm. In a telephone interview on 05/01/2024 at 8:45 AM, the MD stated he was not aware of Resident #1's wound until the facility called him on 04/21/2024 informing him of the worsening wound. He said he instructed them to clean and dress the wound and refer to the WCD on 04/22/2024. He said he had seen Resident #1 since her return to the facility on [DATE] but did not know she had a wound. He said he would expect to be informed of any wounds and would put treatment orders in place until the resident could be seen by the WCD. He said everyone who had a wound needed to be seen by the WCD to prevent new or worsening wounds. He said it seemed the delay in obtaining consent and coordination to see the wound care doctor delayed Resident #1's appropriate wound care and caused it to worsen. Record review of LVN A's nurse note dated 03/28/2024 at 4:15 PM, reflected, [Resident #1] readmitted to facility . observed having 2 small openings on each buttock, 3 cm x 2 cm on left and 2 cm x 2 cm on right, cleaned area and applied house cream . Record review of LVN E's nurse note dated 04/20/2024 at 12:00 PM, reflected, [Resident #1] was assessed after night nurse asked to follow up on findings of a open area, When assessed resident was noted to have 2 deep wounds to sacrum area, with moderate drainage. [RN G] made aware of findings. [RN G] called DON to make aware, DON stated that the family is aware of findings, family wanted only Coloplast cream to be put on wound. When relieved by evening nurse [ADON B] was made aware of findings, nurse stated she was aware of wound, and that family denied wanting any other treatment but a thick layer of the Coloplast to be put on her wound. Record review of the Weekly Wound Progress note dated 04/22/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the RP and Physician were notified 04/22/24. The wound was described as an unstageable pressure ulcer to the sacrum; Heavy exudate; an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 10 cm x 12 cm x 0.1 cm. Additional Comments: Wound MD Recommend to send to the hospital for surgical debridement. Record review of the Hospital CT findings on admission reflected, Large collection of gas and debris in the posterior midline and right of midline overlying the coccyx and inferior sacrum. Overall size of this is about 4 cm AP by a maximum of 4.3 cm transverse. Craniocaudal dimensions are about 14 cm but it should be noted that this is not 1 uniform collection. Pockets of mottled collection of gas with some areas containing debris. No definite drainable fluid collection is present. Portions of this inflammatory process about the coccyx, axial image 60 series 3, sagittal image 18 series 6 but no definite periosteal reaction at this time though early osteomyelitis would be difficult to fully exclude. The Administrator, DON and Regional Clinical Services Director were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/26/2024 at 5:15 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 04/27/2024 at 12:30 PM and included: In-Service conducted. DON, ADON, Wound Care Nurse and Administrator were re-educated by the Regional Clinical Services Director on policy for completing weekly skin assessments, Notification of Physician for Orders/Change of Condition and Prevention and Treatment of Pressure Ulcers. This was completed on 04/26/24. DON started re-education of nurses on 04/24/24 on completing weekly skin assessments, Notification of Physician for Orders and notifying DON/Wound Care Nurse of any new areas identified. This was completed on 4/26/24. All facility licensed nurses received education on timely notification of Physician, Pressure Ulcer Prevention and Identification and Documentation of Pressure Ulcers/Skin Conditions from Clinical Specialists in Wound Care and DON this was initiated and completed 04/26/24. Nurses who are off, on vacation or leave of absence will be provided education prior returning to work. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation: IDT will review all Pressure Ulcers, Arterial/Stasis Ulcers or any other significant wound weekly during clinical WE CARE Meeting. All newly identified skin issues will be assessed by Wound Nurse and DON upon identification. Physician will be notified by charge nurse upon discovery of any new wound. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO will monitor compliance weekly. Implementation Date of Changes In-servicing was initiated on 04/24/24 and was completed on 04/26/24 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Agency in-serve template was placed in the agency orientation binder on 04/26/24. At this time the facility is not utilizing agency staff. Involvement of Medical Director The Medical Director, was notified about the immediate Jeopardy on 04/26/24. Monitoring of the POR DON/Designee will monitor for compliance daily during clinical round and weekly during weekly skin rounds for 4 weeks. Involvement of QA QAPI reviewed and approved the Plan of Removal on 04/26/24. QAPI will review plan for compliance monthly for 3 months. Who is responsible for implementation of process? Administrator and DON (Director of Nursing). On 04/27/2024 at 2:00 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 04/27/2024 between 2:15 PM and 4:00 PM with RN G, LVN H, CNA I, CNA J, CNA K, LVN L, LVN M, and LVN N. Interviews with staff represented 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice including the identification of changes in wound condition, prevention strategies for pressure ulcers, reporting changes to the DON and physician, requesting physician orders when a change in wound condition is noted, and documenting wound status. All staff stated the DON would monitor these actions. In an interview on 04/27/2024 at 4:45 PM, the DON stated, she understood that the facility failed to ensure all wounds were seen by the physician promptly and ensure treatment orders were in place. She said she had been in serviced by the Regional Director of Clinical Services on the following: new and worsening skin, consulting with the MD, referring to the Wound Care Physician, documenting changes in condition in the 24-hour report, and entering MD orders She said they have initiated in services with staff on these topics and will continue until all staff have been in serviced. She said she would monitor this though chart reviews. In an interview on 04/27/2024 at 4:57 PM, the Administrator stated the DON, both ADONs (including ADON A - Wound Care Nurse) were in serviced by the Regional Director of Clinical Services. She stated all nursing staff were educated on notification of Physician, pressure ulcer prevention and identification and documentation of pressure ulcers/skin conditions from by an outside company specializing in wound care. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. Record review of the facility's in-service record dated 04/26/2024, and titled, Prevention, identification and notification for pressure ulcers, timely treatment, orders, and POR, reflected the in-services as conducted by the Regional Director of Clinical Services and included signatures of the Administrator, DON, and both ADONs. She stated in-servicing will be on-going to ensure all staff understand the facility's expectations. Record review of the facility's in-service record addressed to CNAs, dated 04/26/2024, and titled, You must notify charge nurse of any issue with skin. All incontinent residents must have [NAME] cream applied after every peri-care. Residents who require total care must be repositioned Q 2-hours. All residents will receive showers per schedule and notify nurse if they refuse. Record review of the facility's in-service record addressed to Nurses, dated 04/26/2024, and titled, Weekly skin assessments: All skin assessment must be completed per schedule. In new skin issues are identified, charge nurse will notify the PCP and DON. Wound nurse will initiate treatment per orders. Notification of the Wound Care Doctor as well. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 9 residents reviewed for pressure ulcers. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at a risk of increased pain, infections, development of new pressure ulcers, and decline in quality of life and serious harm for residents. Findings included: Record review of Resident #1's face sheet dated 04/23/2024 indicated an [AGE] year-old female initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (mile cognitive impairment), congestive heart failure (heart does not bump blood enough to meet the body's needs), hypertension (pressure in blood vessels is too high), and Type 2 diabetes (problems in the way the body regulates and uses sugar as fuel). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 4, indicating severe cognitive impairment. Resident #1 required supervision for eating, substantial/maximal assistance with toileting and personal hygiene, and dependent for transfer. She was always incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers/injuries, she did not have any unhealed pressure ulcers/injuries but had moisture associated skin damage - treatments include applications of ointments/medications. Record review of Resident #1's Comprehensive Care Plan dated 03/14/2024 reflected, [Resident #1] has an ADL self-care performance deficit r/t impaired gait2/balance, poor comprehension r/t Dementia/Alzheimer's, revised on 03/25/2024. Interventions included extensive to total x 2 for bed mobility, transfers, dressing, and toileting. [Resident #1] has actual impairment to skin integrity of the peri area r/t incontinence. Interventions: Triad cream per family request, initiated 04/04/2024. Record review of Resident #1's March 2024 Nursing MAR reflected Preventative Skin Care: Apply Moisture Barrier every shift and PRN. Start Date - 03/29/2024. D/C Date - 03/28/2024. Record review of Resident #1's March 2024 TAR did not reflect treatment orders. Record review of Resident #1's April 2024 Nursing MAR and TAR did not reflect treatment orders. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. The site(s), type, measurements, or stage were not identified. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. An unmeasured pressure wound was identified to the left and right buttocks. An unmeasured open area was identified to the Coccyx. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Wound Progress note 04/21/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the notified RP and date were blank. The physician was notified 04/21/24. The wound type was other and the location reflected wound has deteriorated rapidly in the past 2 days; Heavy exudate (drainage that seeps out of wounds); an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 9 cm x 10 cm x 0.5 cm. Additional Comments: WOUND HAS DETERIORATED LOOKS LIKE ABSCESS. Doctor notified with orders for wound care ASAP. In an interview on 04/23/2024 at 11:25 AM, ADON B stated she was the Wound Care Nurse. She said when Resident #1 admitted to the facility on [DATE], she did not have any wounds. She said Resident #1 was sent to the hospital for a UTI and returned to the facility on [DATE] with two small open wounds on her right and left buttocks. She said the family wanted them treated with cream they brought in because that seemed to help in the past. She said she did not consult the MD or Wound Care Doctor about the wounds because she attributed them to moisture related and only warranted barrier cream. She stated she completed Resident #1's wound care daily and the wound did not get better or worse. She said on 04/04/2024 she started pursuit of having the family sign a consent form to see the Wound Care Doctor because Resident #1 did not get out of bed and the wounds were not getting better. She said she did not consult with the Wound care Doctor because they would not see Resident #1 without a consent. She said she was able to have the family complete the consent on 04/08/2024 but the Wound care Doctor had already rounded for the day and did not see Resident #1. She said she had not discussed Resident #1 with the Wound Care Doctor on 04/08/2024 because she did not have the consent signed until after the Doctor left the facility. She said she was not aware that LVN A had documented the development of another wound on Resident #1's sacrum, during a skin assessment on 04/11/2024. She said the Wound care Doctor was next in the facility on 04/15/2024 but she was late on that day and was not able to provide the consent to the Doctor, therefore the Doctor, did not see Resident #1's wounds again. She stated she last saw Resident #1's wounds on 04/18/2024 and they looked normal to her. She said she worked on 04/21/2024 and LVN E called her to look at Resident #1's wound. She said it deteriorated a lot and seemed to have an abscess and measured 9 cm x 10 cm x 0.5 cm. She stated the MD was notified by LVN E and the MD told them to clean and dress the wound and referred to the WCD on 04/22/2024. She said she had not consulted with the MD or the WCD about Resident #1's wounds until 04/22/2024 when the Wound Care Doctor sent Resident #1 to the hospital for possible debridement. ADON A stated she did wound care daily, which included applying cream to the wound and dressing it, Monday through Friday and the nurses followed up with wound care on the weekends. She said it was important to follow doctor's orders for wound care, but the family only wanted triad cream applied to the wound. She said she should have consulted the WCD on 04/04/2024 when she initially felt Resident #1 should be seen by the WCD. In an interview on 04/23/2024 at 12:33 PM, the DON stated, Resident #1 returned to the facility on [DATE] from the hospital with an opening (sheer) on the sacrum. She stated the family only wanted the wound to be treated with cream. She said the family was to sign a consent for Resident #1 to see the WCD and did on 04/08/2024 after the WCD had already left the facility. She said the facility needed a consent for residents to see the WCD but not to consult with them. She said the next time the WCD was in the facility on 04/15/24, the WCN was late, and they missed each other. Resident #1 was not seen by the WCD. She said the WCN should have discussed the wound with the WCD or MD to get treatment orders in place. She said she needed to put a system in place for someone else to round with the WCD in the WCN's absence. She said on 04/22/2024, RN G called her to tell her about Resident #1's wound. She said LVN E called the MD and was instructed to clean and dress the wound and refer to the WCD the next day, 04/22/2024. She said Resident #1 was sent to the hospital by the WCD on 04/22/24. She said she expected nursing staff to follow the facility's policy and ensure they consulted the physician when changes in skin are noted. She said she expected staff to obtain and follow treatment order for all wounds. In a telephone interview on 04/23/2024 at 1:38 PM, the WCD stated she did not see residents unless there was a referral and consent completed. She said she knew the WCN was getting a consent from the facility but had not discussed the wounds with her. She said she came to the facility every Monday and on 04/15/2024 Resident #1 was not on her list of residents to see. She said the WCN was not there that day. She said the WCN provided the consents and list of residents to see. She said she would like to be notified and consulted of wound changes for all residents because wounds can deteriorate quickly. She said all wounds should have treatment orders in place if not from the WCD then from the MD. In an interview on 04/23/2024 at 1:46 PM, CNA D stated when Resident #1 returned to the facility from the hospital on [DATE], she had a small opening on her bottom and the family wanted them to use cream to treat it. She said they placed signage on the walls directing this. She said she worked with Resident #1 on 04/10/2024 and again on 04/17/2024 and 04/18/2024 the wound looked the same. She said she worked with Resident #1 on 04/22/2024 and the wound looked like it burst and was huge. In an interview on 04/23/2024 at 1:53 PM, LVN C stated she sent Resident #1 to the hospital on [DATE] by the WCD. She said the wound had grown, was very deep and the skin was all gone. She said it had not been like that last week. She said she had not been notified that it had worsened. An observation on 04/23/2024 at 4:15 PM at the hospital, of Resident #1 revealed her sleeping. She was propped on her side with wedges. In an interview on 04/23/2024 at 4:20 PM, Family Member O stated Resident #1 returned to the facility from the hospital on [DATE]. She said Resident #1's wound was about the size of a quarter and not deep or oozing but it was a little red. She said she brought cream to the facility for them to use on the wound because that seemed to help in the past. She said the WCN did not ask her to sign a consent for Resident #1 to see the WCD until 04/08/2024 and it was provided immediately. She said on 04/21/2024 the facility called her and said the wound had gotten larger and started oozing. She said the WCD saw Resident #1 on 04/22/2024 and sent her to the hospital. She said Resident #1 had surgery to remove infection. In an interview on 04/23/2024 at 4:30 PM, Hospital RN P said Resident #1 had debridement surgery this morning. She said there was an ulcer under the wound which burst and revealed deep tissue damage. She said they used wedges to position Resident #1 on her side and they alternate every 2 hours. In an interview on 04/26/2024 at 2:10 PM, LVN A stated she did the readmission assessment for Resident #1 when she returned to the facility on [DATE]. She said Resident #1 did have open areas on her buttocks. She said the top layer of skin was off. She said the family wanted to use cream on the wound and she entered that into the orders. She said she had not consulted with the MD about the cream treatment. She said when she did the skin assessment on 04/11/2024, an additional wound was on the coccyx. She said the MD should be informed of all wound changes and treatment orders requested. In an interview on 04/26/2024 at 2:49 PM, ADON B stated - she did not open the weekly skin assessments but used the report to identify new wounds and follow up, she said she would let the MD know about new wounds and request treatment orders then enter them into the clinical record. She said she did not do that for Resident #1 because the family only wanted the use of cream. She said she followed up with wounds as best she could but often had to work as a floor nurse. She said the risk to residents of not consulting the MD or WCD could result in new or worsening wounds. In a telephone interview on 04/26/2024 at 3:28 PM, LVN E stated, she called RN G on 04/20/2024 about Resident #1's deteriorating wound and informed her there were no wound treatment orders in the clinical record. She said RN G contacted the DON and they told her the family was aware of the wound and only wanted cream as treatments. She said the wound on Resident #1's right buttock was open and not as deep as the wound on the left buttocks and there was not drainage. LVN E said on 04/21/2024, Resident #1's wound was worse and developed some odor and drainage. LVN E said she notified the MD who instructed her to clean and dress the wound then refer to the WCD on 04/22/2024. In an interview on 04/26/2024 at 3:28 PM, ADON F stated when the WCN was not available nursing staff typically called her to round with the WCD. She said all treatments needed to be order and nurses needed to follow doctor's orders. She said she expected skin assessments to be completed weekly and documented in the clinical record. She said if there were changes they needed to be noted in the 24-hour report for follow up. In an interview on 04/26/2024 at 3:28 PM, RN G stated, LVN E called her on 04/20/2024 to inform her that Resident #1 did not have wound treatment orders in place. She said she asked the WCN who told her the family only wanted the wound treated with cream they brought from home. She said it did not make sense to her and called the DON who told her the same thing. She said the WCD should have seen Resident #1 on their next visit to the facility on [DATE]. She said there was not documentation that the MD or WCD had seen the wound or that treatment orders were requested. She said not consulting the MD or requesting treatment orders placed Residents at risk of worsening wounds and harm. In a telephone interview on 05/01/2024 at 8:45 AM, the MD stated he was not aware of Resident #1's wound until the facility called him on 04/21/2024 informing him of the worsening wound. He said he instructed them to clean and dress the wound and refer to the WCD on 04/22/2024. He said he had seen Resident #1 since her return to the facility on [DATE] but did not know she had a wound. He said he would expect to be informed of any wounds and would put treatment orders in place until the resident could be seen by the WCD. He said everyone who had a wound needed to be seen by the WCD to prevent new or worsening wounds. He said it seemed the delay in obtaining consent and coordination to see the wound care doctor delayed Resident #1's appropriate wound care and caused it to worsen. Record review of LVN A's nurse note dated 03/28/2024 at 4:15 PM, reflected, [Resident #1] readmitted to facility . observed having 2 small openings on each buttock, 3 cm x 2 cm on left and 2 cm x 2 cm on right, cleaned area and applied house cream . Record review of LVN E's nurse note dated 04/20/2024 at 12:00 PM, reflected, [Resident #1] was assessed after night nurse asked to follow up on findings of a open area, When assessed resident was noted to have 2 deep wounds to sacrum area, with moderate drainage. [RN G] made aware of findings. [RN G] called DON to make aware, DON stated that the family is aware of findings, family wanted only Coloplast cream to be put on wound. When relieved by evening nurse [ADON B] was made aware of findings, nurse stated she was aware of wound, and that family denied wanting any other treatment but a thick layer of the Coloplast to be put on her wound. Record review of the Weekly Wound Progress note dated 04/22/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the RP and Physician were notified 04/22/24. The wound was described as an unstageable pressure ulcer to the sacrum; Heavy exudate; an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 10 cm x 12 cm x 0.1 cm. Additional Comments: Wound MD Recommend to send to the hospital for surgical debridement. Record review of the Hospital CT findings on admission reflected, Large collection of gas and debris in the posterior midline and right of midline overlying the coccyx and inferior sacrum. Overall size of this is about 4 cm AP by a maximum of 4.3 cm transverse. Craniocaudal dimensions are about 14 cm but it should be noted that this is not 1 uniform collection. Pockets of mottled collection of gas with some areas containing debris. No definite drainable fluid collection is present. Portions of this inflammatory process about the coccyx, axial image 60 series 3, sagittal image 18 series 6 but no definite periosteal reaction at this time though early osteomyelitis would be difficult to fully exclude. The Administrator, DON and Regional Clinical Services Director were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/26/2024 at 5:15 PM, due to the above failures and the IJ template were provided. The facility's Plan of Removal was accepted on 04/27/2024 at 12:30 PM and included: In-Service conducted. DON, ADON, Wound Care Nurse and Administrator were re-educated by the Regional Clinical Services Director on policy for completing weekly skin assessments, Notification of Physician for Orders/Change of Condition and Prevention and Treatment of Pressure Ulcers. This was completed on 04/26/24. DON started re-education of nurses on 04/24/24 on completing weekly skin assessments, Notification of Physician for Orders and notifying DON/Wound Care Nurse of any new areas identified. This was completed on 4/26/24. All facility licensed nurses received education on timely notification of Physician, Pressure Ulcer Prevention and Identification and Documentation of Pressure Ulcers/Skin Conditions from Clinical Specialists in Wound Care and DON, this was initiated and completed 04/26/24. Nurses who are off, on vacation or leave of absence will be provided education prior returning to work. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation: IDT will review all Pressure Ulcers, Arterial/Stasis Ulcers or any other significant wound weekly during clinical WE CARE Meeting. All newly identified skin issues will be assessed by Wound Nurse and DON upon identification. Physician will be notified by charge nurse upon discovery of any new wound. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO will monitor compliance weekly. Implementation Date of Changes In-servicing was initiated on 04/24/24 and was completed on 04/26/24 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Agency in-serve template was placed in the agency orientation binder on 04/26/24. At this time the facility is not utilizing agency staff. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 04/26/24. Monitoring of the POR DON/Designee will monitor for compliance daily during clinical round and weekly during weekly skin rounds for 4 weeks. Involvement of QA QAPI reviewed and approved the Plan of Removal on 04/26/24. QAPI will review plan for compliance monthly for 3 months. Who is responsible for implementation of process? Administrator and DON (Director of Nursing). On 04/27/2024 at 2:00 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 04/27/2024 between 2:15 PM and 4:00 PM with RN G, LVN H, CNA I, CNA J, CNA K, LVN L, LVN M, and LVN N. Interviews with staff represented 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice including the identification of changes in wound condition, prevention strategies for pressure ulcers, reporting changes to the DON and physician, requesting physician orders when a change in wound condition is noted, and documenting wound status. All staff stated the DON would monitor these actions. In an interview on 04/27/2024 at 4:45 PM, the DON stated, she understood that the facility failed to ensure all wounds were seen by the physician promptly and ensure treatment orders were in place. She said she had been in serviced by the Regional Director of Clinical Services on the following: new and worsening skin, consulting with the MD, referring to the Wound Care Physician, documenting changes in condition in the 24-hour report, and entering MD orders She said they have initiated in services with staff on these topics and will continue until all staff have been in serviced. She said she would monitor this though chart reviews. In an interview on 04/27/2024 at 4:57 PM, the Administrator stated the DON, both ADONs (including ADON A - Wound Care Nurse) were in serviced by the Regional Director of Clinical Services. She stated all nursing staff were educated on notification of Physician, pressure ulcer prevention and identification and documentation of pressure ulcers/skin conditions from by an outside company specializing in wound care. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. Record review of the facility's in-service record dated 04/26/2024, and titled, Prevention, identification and notification for pressure ulcers, timely treatment, orders, and POR, reflected the in-services as conducted by the Regional Director of Clinical Services and included signatures of the Administrator, DON, and both ADONs. She stated in-servicing will be on-going to ensure all staff understand the facility's expectations. Record review of the facility's in-service record addressed to CNAs, dated 04/26/2024, and titled, You must notify charge nurse of any issue with skin. All incontinent residents must have [NAME] cream applied after every peri-care. Residents who require total care must be repositioned Q 2-hours. All residents will receive showers per schedule and notify nurse if they refuse. Record review of the facility's in-service record addressed to Nurses, dated 04/26/2024, and titled, Weekly skin assessments: All skin assessment must be completed per schedule. In new skin issues are identified, charge nurse will notify the PCP and DON. Wound nurse will initiate treatment per orders. Notification of the Wound Care Doctor as well. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of nine residents reviewed for a change of condition: -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by others and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflected Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place c-collar [neck brace] . EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records from the local hospital, dated 10/11/23, revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on [DATE] during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24-report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for 37 years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details On 10/12/2023, an Incident Investigation Survey was initiated at [nursing facility]. On 10/13/2023, a surveyor provided an Immediate Jeopardy Template notification that the Survey Agency determined that the conditions existed that constituted Immediate Jeopardy to resident health and well-being. Allegation F580 Notification of Physician - The facility failed to notify the physician when there was a change in the resident's mental and psychological status, which led to a serious injury. The facility's failure to provide services who required insulin resulted in the resident falling and sustaining serious injuries. Identify residents who could be affected, Resident [Resident #1] was assessed by the Charge Nurse prior to discharge. Three sets of neuro checks, and vital signs were obtained, first aid was provided, and MD was notified. Prior to the incident, resident was placed on frequent monitoring and staff was in the resident room checking on his needs a total of 10 times in a 6 hour period. Resident continued to resist care throughout the shift. It was also noted in the EMT report that the resident was resistant to care provided by the EMT. All Residents have the potential to be affected. The Facility census on 10/13/23 is 75. An audit will be completed on 10/13/23 for 100% of the residents to assess for any change of condition by [DON] In-Service conducted: All nurses will receive education on proper notification Change of Condition, documentation in clinical record and Notification of Physician. Education will include use of the INTERACT tools. Implementation Date of Changes In-servicing was initiated on 10/13/23 by the DON and will continue until it is completed by the DON/Designee on 10/14/23. DON and ADON will receive the same education from the Regional Director of Clinical Services. Agency staff and/or staff on leave that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Monitoring Administrator/DON/Designee will monitor change of resident status and appropriate notification, interventions, and outcomes Administrator/DON will notify Physician, Regional Nurse, and QAPI Committee of any noncompliance to plan. Involvement of Medical Director The Medical Director [MD] as notified about the immediate Jeopardy on 10/13/23. Involvement of QA QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for implementation of process? Administrator and DON. Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of nine residents reviewed for neglect. -The facility staff were aware of the goods and services Resident #1 required per his care plan and orders, and failed to provide them (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 2.Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records, dated 10/11/23, from the local hospital revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on [DATE] during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for 37 years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes. On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 Neglect - The facility failed to ensure a resident was free from neglect by failing to provide services to a resident with Diabetes who required insulin which led to physical harm. The failure resulted in the resident falling and sustaining a serious injury. The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected: Resident [Resident #1] was resistant to care on admission on [DATE]. Resident missed one finger stick blood sugar test and one dose of insulin due to resistance to care on 10/10/23. MD was contacted on 10/14/23 to inquire about what next steps we should have taken to intervene with a resident who is resistant to care. MD stated she would have told staff to recheck the blood sugar the next morning if the resident remained combative. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day. In-Service Conducted Nurse that was involved in resident's [Resident #1] care and who failed to document the resident's resistance to finger stick and insulin administration was previously counseled for failure to document. Subsequently, on 10/13/12, termination of employment was issued for the same failure to document properly. All staff will receive re-education on Abuse, Mistreatment, and Neglect. Specifically, what constitutes potential neglect. Any staff who are on Leave of Absence or are PRN who have not been able to be contacted will not be allowed to work until such in-services have been completed. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same In-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The Medical Director, was notified about the Immediate Jeopardy on 10/13/23. Involvement of QAPI QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one resident (Resident #1) of nine residents reviewed for neglect. -The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1 by not providing him goods and services (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records, dated 10/11/23, from the local hospital revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on [DATE] during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for 37 years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes. On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 Neglect - The facility failed to ensure a resident was free from neglect by failing to provide services to a resident with Diabetes who required insulin which led to physical harm. The failure resulted in the resident falling and sustaining a serious injury. The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected: Resident [Resident #1] was resistant to care on admission on [DATE]. Resident missed one finger stick blood sugar test and one dose of insulin due to resistance to care on 10/10/23. MD was contacted on 10/14/23 to inquire about what next steps we should have taken to intervene with a resident who is resistant to care. MD stated she would have told staff to recheck the blood sugar the next morning if the resident remained combative. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day. In-Service Conducted Nurse that was involved in resident's [Resident #1] care and who failed to document the resident's resistance to finger stick and insulin administration was previously counseled for failure to document. Subsequently, on 10/13/12, termination of employment was issued for the same failure to document properly. All staff will receive re-education on Abuse, Mistreatment, and Neglect. Specifically, what constitutes potential neglect. Any staff who are on Leave of Absence or are PRN who have not been able to be contacted will not be allowed to work until such in-services have been completed. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same In-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The Medical Director, was notified about the Immediate Jeopardy on 10/13/23. Involvement of QAPI QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of nine residents reviewed for change in physical, mental, or psychosocial status. -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records from the local hospital, dated 10/11/23, revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on [DATE] during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for 37 years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F 684 Quality of Care The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected. Resident [Resident #1] was assessed by the Charge Nurse prior to discharge. Three sets of neuro checks, and vital signs were obtained, first aid was provided, and MD was notified. Prior to the incident, resident was placed on frequent monitoring and staff was in the resident room checking on his needs a total of 10 times in a 6-hour period. Resident continued to resist care throughout the shift. It was also noted in the EMT report that resident was resistant to care provided by the EMT. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day by [MDS Coordinator]. In-Services Conducted All nurses will receive education on Diabetes Clinical Protocol, documentation in the clinical record (including notification to physician), and use of the SBAR/INTERACT Tool to assess a significant change of condition. Nurses were also provided with education on the process for identifying a residents change of condition or status, including the Nurse making detailed observations and gathering relevant and pertinent information. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same in-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [Medical Director] was notified about the immediate Jeopardy on 10/13/23. Involvement of QA QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #38) of 17 residents reviewed for labs and diagnostics. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries: 05/08/23 7:53 AM This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain 05/08/23 8:12 AM Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted 05/08/23 9:38 AM Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. 05/08/23 1:06 PM .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement 05/08/23 1:20 PM Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. 05/08/23 6:40 PM Xray tech arrived and completed xray to R shoulder R hip. Will wait for results 05/09/23 5:56 AM Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. 05/09/23 8:00 AM When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment 05/09/23 12:04 PM Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following: Right Shoulder X-Ray . Impression: The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement . Review of Resident #38's hospital records dated 05/09/23 reflected the following: .Diagnosis Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report. Review of the 24-hour report dated 05/08/23 reflected the following: .[Resident #38] REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow. REMARKS(EVENING) - Results pending Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was. Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following: .1. When test results are reported to the facility, a nurse will first review the results. a. If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure Identifying Situations that Warrant Immediate Notification 1. Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following: The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 5/11/23 was 68. An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted RDCS completed in-service with DON/ADON on all education to be provided and the POR. All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures. All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting. All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO are monitoring implementation of Implementation Date of Changes In-servicing was initiated on 5/11/23 and will be completed by 5/11/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. Involvement of QA QAPI will review and approve Plan of Removal on 5/11/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing). Monitoring of the facility's implementation of the Plan of Removal revealed the following Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #38) of four residents reviewed diagnostic services. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries: 05/08/23 7:53 AM This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain 05/08/23 8:12 AM Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted 05/08/23 9:38 AM Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. 05/08/23 1:06 PM .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement 05/08/23 1:20 PM Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. 05/08/23 6:40 PM Xray tech arrived and completed xray to R shoulder R hip. Will wait for results 05/09/23 5:56 AM Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. 05/09/23 8:00 AM When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment 05/09/23 12:04 PM Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following: Right Shoulder X-Ray . Impression: The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement . Review of Resident #38's hospital records dated 05/09/23 reflected the following: .Diagnosis Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report. Review of the 24-hour report dated 05/08/23 reflected the following: .[Resident #38] REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow. REMARKS(EVENING) - Results pending Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was. Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following: .1. When test results are reported to the facility, a nurse will first review the results. a. If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure Identifying Situations that Warrant Immediate Notification 1. Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following: The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 5/11/23 was 68. An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted RDCS completed in-service with DON/ADON on all education to be provided and the POR. All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures. All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting. All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO are monitoring implementation of Implementation Date of Changes In-servicing was initiated on 5/11/23 and will be completed by 5/11/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. Involvement of QA QAPI will review and approve Plan of Removal on 5/11/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing). Monitoring of the facility's implementation of the Plan of Removal revealed the following Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could place residents at risk of harm and/or serious injury. Findings included: Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date. Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following: Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following: Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following: Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. Review of Resident #1's hospital records dated 02/18/23 reflected the following: Reason for visit: Fall Diagnosis: facial laceration Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy. Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents. An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.